Deficiency in Accurate Medical Record Documentation
Summary
The facility failed to ensure accurate and complete documentation for a resident, leading to a deficiency in maintaining medical records. The resident, who had been admitted with diagnoses including idiopathic conditions, acute failure, and dependence on supplemental support, experienced a change in condition related to decreased food and fluid intake. Despite the situation being assessed and the provider being notified, the clinical record did not accurately reflect the events that transpired, including the initiation of emergency procedures and the calling of Emergency Medical Transport (EMT). The Director of Nursing (DON) confirmed that the clinical record and transfer form did not document the emergency intervention that was administered. The facility's policy on documentation requires that each resident's medical record accurately represent their experiences and include timely and complete information. However, in this case, the documentation was not completed in accordance with the facility's policy, as it failed to capture the critical interventions and notifications made during the resident's change in condition.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Penalty
A resident with peripheral vascular disease and a Stage 4 pressure ulcer had a physician’s order for Tramadol to be given on the day shift 30 minutes before wound care, consistent with the care plan and the facility’s pressure ulcer protocol requiring pain assessment and documentation. Review of the MAR for one month showed multiple missing nurse signatures for this ordered pain medication and several entries marked “out of parameters” by an RN without any corresponding progress notes, while the Treatment Record showed that daily wound care was performed. During observed wound care the resident denied pain, and the Wound Care Nurse reported she checks the MAR to verify medication administration, while the DON stated nurses must follow physician orders and document refusals, highlighting that the medical record did not contain complete and accurate documentation of the ordered pre-wound-care pain medication.
Two residents had physician orders for compression stockings, but staff documented in the MAR that the stockings were applied when, in fact, they were not. Both residents and their caregivers confirmed the stockings were never applied, and staff admitted to inaccurate documentation. The DON acknowledged the medical records did not accurately reflect the care provided.
A resident's medical records inaccurately documented a COVID-19 positive status and treatment with a Z pack, despite being COVID-19 negative and not receiving such medication. This discrepancy was confirmed by the DON and an LPN, highlighting a failure to maintain accurate records as per facility policies.
A facility failed to update a resident's nutritional care plan, resulting in a discrepancy between the care plan and the physician's order. The resident, dependent on tube feeding, was receiving Jevity 1.5 as per the physician's order, but the care plan inaccurately listed Isosource 1.5. A dietary technician admitted to forgetting to update the care plan, despite facility policy requiring timely revisions.
A resident with type 2 diabetes experienced severe pain and did not receive timely medication. When the RN administered the medication, it was not documented in the MAR, and the resident's pain level was not assessed. Facility policies require accurate documentation, which was not followed, resulting in a deficiency.
A resident with complex medical conditions did not receive Sevelamer as prescribed due to unavailability, and the facility failed to accurately document the administration in the MAR. Despite daily communication with the pharmacy, the medication was not delivered on time, and the lack of documentation of these efforts contributed to the deficiency.
Incomplete Documentation of Pre-Wound-Care Pain Medication for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves incomplete and inadequate medical record documentation for a resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan initiated and revised for a pressure ulcer, with interventions directing staff to administer medications and treatments as ordered by the physician. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, was on a scheduled pain medication regimen, and experienced moderate, occasional pain in the prior five days. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates, despite the Treatment Record reflecting that wound care was performed daily on the day shift. Specifically, there were no signatures on the MAR for the Tramadol dose on four listed dates, and on several other dates the MAR entries were coded as “out of parameters” by an RN without any associated progress notes explaining these entries. During observation of wound care, the resident denied pain at that time, and the Wound Care Nurse stated she checks the MAR to ensure the pre-wound-care pain medication is given and that she performs wound care Monday through Friday while the floor nurse does it on weekends. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the clinical record lacked complete, accurate, and properly documented information regarding administration or non-administration of the ordered pre-wound-care pain medication.
Plan Of Correction
N0101 The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident# 62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Inaccurate Documentation of Compression Stocking Application
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents regarding the application of physician-ordered compression stockings. For one resident, the medical record and Medication Administration Record (MAR) indicated that anti-embolic stockings were applied daily as ordered by the physician. However, multiple observations showed the resident was not wearing the stockings at various times, and both the resident and her private duty aide confirmed that the stockings were never applied. The CNA responsible for the resident stated she was not instructed to apply the stockings, and the RN admitted to documenting their application in the MAR despite knowing they were not applied. The Director of Nursing (DON) confirmed that documentation should not reflect treatments that were not completed, acknowledging the inaccuracy of the MAR. Similarly, for another resident, the MAR documented that compression stockings were applied every shift as ordered. Observations throughout the day showed the resident was not wearing the stockings, and the resident stated he had never worn them at the facility and was not provided with a pair. The CNA confirmed she was not told to apply the stockings, and the RN admitted to documenting their application without verifying if they were actually applied. The DON again confirmed that the medical record was inaccurate in this instance. Photographic evidence was obtained to support these findings.
Plan Of Correction
Resident #13 had an order that was discontinued on [date]. Resident #133 had a physician order reviewed and placed for the remainder of his stay. The resident was discharged on [date]. Education was provided to licensed nurses, ARNPs, and physicians on the need for medical records to be complete and accurate. Audit medical records to ensure professional standards of practice are being followed in regards to documentation of orders. Audits are to be conducted to ensure compliance with professional standards of practice by the DON/designee, including documentation of orders daily for four weeks, and three times a week for eight weeks thereafter. Results are to be taken to the monthly QAPI meeting for three months.
Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, as required by professional standards and practices. The deficiency was identified when a Nurses' Progress Note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, both of whom stated that the resident did not have COVID-19 and was not receiving the mentioned treatment. The resident in question had a severe mental status as indicated by a Brief Interview of Mental Status Summary Score of 00, requiring dependent assistance for activities of daily living. The resident's demographic sheet and Minimum Data Set Quarterly Assessment were reviewed, revealing diagnoses including protein-calorie malnutrition and atherosclerotic conditions. Despite these documented conditions, the medical records inaccurately reflected the resident's COVID-19 status and treatment, which could potentially affect the care provided. The facility's policies on charting and documentation, as well as charting errors and omissions, were reviewed. These policies require that all services and changes in a resident's condition be accurately documented by licensed personnel. However, the inaccurate entry in the resident's medical record was not corrected, highlighting a failure to adhere to these policies. This inaccuracy in medical records has the potential to impact the care of any resident within the facility.
Plan Of Correction
N101-FAC Resident Medical Records Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patients that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records - Identifiable Information and Resident Accuracy was started for all nurses on an ongoing basis. Example of Error identified was presented and discussed. Thereafter, the DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on a weekly review. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Inaccurate Documentation of Nutritional Care Plan
Penalty
Summary
The facility failed to accurately document a nutritional care plan for a resident, identified as Resident #31, which led to a discrepancy between the care plan and the physician's order. The resident was observed receiving tube feeding at a rate of 50 milliliters per hour, consistent with the physician's order for Jevity 1.5. However, the care plan inaccurately listed Isosource 1.5 as the prescribed formula, which was not updated to reflect the current physician's order. The resident, who was initially admitted and later readmitted to the facility, has a diagnosis that requires attention to nutritional and hydration needs. The resident is severely dependent on assistance for activities of daily living and requires tube feeding as part of their care. The physician's order specified Jevity 1.5 at 50 ml/hr for 20 hours, with specific times for the feeding to be turned off and on. Despite this, the care plan was not updated to match the physician's order, leading to a discrepancy in the documented care plan. During an interview, a dietary technician acknowledged the oversight, stating that the care plans are updated quarterly or when changes occur, but admitted to forgetting to update the care plan in this instance. The facility's policy requires comprehensive, person-centered care plans that are revised as residents' conditions change, but this was not adhered to in the case of Resident #31, resulting in the documented deficiency.
Plan Of Correction
F842 Residents Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(h)(1)-(5) Plan for specific resident: Dietary technician updated the care plan (Resident #31) on technician adjusted the formula jevity 1.5 to ensure facility is in compliance. Quality Assurance Coordinator along with interdisciplinary team conducted a review on showing that (Resident #31) required an update in resident care plan. The care plan was updated and revised to include the current condition of (Resident #31) and necessary interventions. Interdisciplinary care plan team will focus on updating resident's care plan as needed or when a change of order is being received. To ensure a care of plan is in place and that residents do receive treatment and care in accordance with professional standards of practice. Method to assume compliance for other residents: On Administrator provided in-service to the interdisciplinary team on the process of revising and updating the care plan based on assessment findings. As of Quality Assurance Coordinator along with interdisciplinary care plan team will review all orders when provided, when care plan is needed or when there is a change in residents care plan intervention. Interdisciplinary team will make proper adjustments to ensure 100% compliance with adequate monitoring and assessment. Findings will be presented to the administrator and DON monthly during Risk management meeting to evaluate the need for further intervention. System: As Quality Assurance Coordinator along with interdisciplinary care plan team will conduct internal audits on a weekly basis to ensure facility is updating all aspects of the resident's care plan including any type of intervention or physician's orders. The Audit will consist of a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, and functional needs. Quality assurance coordinator along with interdisciplinary team will ensure that residents care plan along with assessments are ongoing and that care plans must be revised as residents' information do change. Monitoring: As of Quality assurance coordinator along with interdisciplinary team will monitor residents care plan for 90 days on a weekly basis or as needed. The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices, which will be completed, accurately documented, readily accessible, and systematically organized to ensure residents plan of care are being audited on a timely basis.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was readmitted to the facility with diagnoses including type 2 diabetes, complained of severe pain rated at 10 out of 10. Despite informing the nurse, the resident did not receive medication promptly. When the Registered Nurse (RN) eventually administered the medication, she failed to document it in the MAR and did not assess the resident's pain level or location before administration. The facility's policies on charting and documentation, as well as medication administration, require that all services provided, including medications administered, be accurately documented in the resident's medical record. However, the RN did not document the administration of the medication or the resident's response to it. The Unit Manager and Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance, leading to a deficiency in the facility's compliance with regulatory standards.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of prn medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses medication administration of 2 residents 3 times a week for 2 weeks then 2 nurse's medication administration for 2 residents once a week for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with diagnoses including an aneurysm of the upper extremity and rapidly progressive nephritic syndrome, had a physician's order for Sevelamer to be administered three times daily. However, the MAR showed discrepancies in the administration times and doses, with some doses documented as given when the medication was not available. Progress notes indicated that the medication was not available on multiple occasions, and the pharmacy was contacted, but the medication was not delivered in a timely manner. The Transitional Care Unit Manager acknowledged that the medication was not available and that she had contacted the pharmacy daily, but these communications were not documented in the resident's medical record. The Director of Nursing stated that she expected accurate documentation and communication with the physician if a medication was not given, but there was uncertainty about the steps taken by the facility's Unit Managers to address the unavailability of Sevelamer. The facility's policy on maintaining medical records emphasized accurate documentation, but this was not adhered to in this instance.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On , the physician for resident #3 was notified of the medication variation/inaccuracy of documentation of administration; new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On , the Director of Nursing/designee completed a 7 day look audit of active residents to ensure accuracy of the medical record and accurate documentation of medication administration to identify other residents having the potential to be affected. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On , the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring accuracy of the clinical record and accurate documentation of medication administration. Newly hired licensed nurses will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents clinical records 3 times weekly X 4 weeks and then weekly X 2 months to ensure accuracy of the clinical record with emphasis on documentation of medication administration. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
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