Health inspection·December 12, 2024

The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint number: CA00928156. A WMF Citation was issued. Regulatory Violation. California Health & Safety Code §1424(f) (1) Any willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the resident's health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of pressure ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. On 11/25/24, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care and death. The facility failed to ensure Resident 1’s medical records were not falsified by staff when Respiratory Therapist 3 (RT 3) documented respiratory assessment and treatments after the resident had expired on 7/30/24 at 3:47 pm. On 7/30/24 at 4:32 pm, RT 3 acting as an employee and agent of the facility, knowingly and willfully falsified the medical records of Resident 1 when he documented treatments of: assess and suction for retained or increased secretions (mucus or fluids); and chest physiotherapy (involves the holistic approach to the prevention, diagnosis and therapeutic management of pain, disorders of movement or optimisation of function to enhance the health and welfare of the community from an individual) while awake. As a result, the facility documented inaccurately in Resident 1’s Respiratory Administration Record (RAR). A review of Resident 1’s admission record indicated Resident 1 a 56 year-old female was admitted to the facility on 8/17/2015 with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), chronic respiratory failure (long-term condition your lungs have a hard time loading your blood with oxygen or removing carbon dioxide) with dependence on supplemental oxygen, tracheostomy (a surgical procedure that creates an opening in the neck to insert a tube into the windpipe to help a person breathe), encephalopathy (disturbance of brain function), dyspnea (shortness of breath, which is the feeling of having difficulty breathing or not being able to breathe deeply enough), muscle weakness . A review of Resident 1’s history and physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 10/3/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 6/18/24, indicated Resident 1 was rarely/never understood, had short- and long-term memory problems, had severe cognitive (thinking, judgement, understanding, reasoning, memory) impairment, and was dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. The same MDS further indicated Resident 1 required oxygen therapy, suctioning, tracheostomy care and invasive mechanical ventilator (tube is connected to a mechanical ventilator that delivers a set amount of air and oxygen, and a specific number of breaths per minute). A review of Resident 1’s “Respiratory Note” entry by Respiratory Therapist 1 (RT 1) dated 7/30/24 at 4:18 pm, indicated that at 2 pm the RT doing rounds noted Resident 1 was patient stable and had no signs of respiratory distress. The Respiratory Note further indicated that at 2:59 pm the RT doing rounds noted Resident 1 resident to be a pale color and RT was, unable to palpate (feel) pulse; a. t 3 pm 911 (emergency phone number) was called by nursing; at, 3:09 pm paramedics arrived;, and at 3:47 paramedics called time of death (TOD). A review of Resident 1’s “Medication Administration Audit Report” dated 7/30/24-7/31/24 indicated that Resident 1 was scheduled to have an (RT) assess and suction for retained or increase secretions and perform chest physiotherapy while awake on 7/30/24 at 5 pm. The report indicated those treatments were documented as done on 7/30/24 at 4:32 pm, which is after the Resident 1’s TOD at 3:47 pm. During a concurrent interview and record review on 11/25/24 at 1:33 pm with RT 1, Resident 1’s RAR for July 2024 was reviewed. The RAR indicated treatments; assess and suction for retained or increased secretions and chest physiotherapy while awake documented by RT 3 for the 5 pm treatment as given. The RT 1 states he does not know why RT 3 would have documented that if the resident had a TOD at 3:47 pm (per RT 1’s respiratory note). During a concurrent interview and record review on 11/25/24 at 2:13 pm with Director of Nursing (DON) Resident 1’s RAR for July 2024 was reviewed. The RAR indicated treatments of:; assess and suction for retained or increased secretions; and chest physiotherapy while awake, documented by RT 3 for the 5 pm treatment as given. The DON verified the documentation and stated it is not acceptable, it could not have happened. A review of the facility’s P&P titled, “Charting and Documentation”, reviewed January 2024 indicated, all services provided to the resident, or any changes in the resident’s medical or mental condition, share be documented in the resident’s medical record… All observation, medications administered, services performed, etc., must be documented in the resident’s clinical records… Entries may only be recorded in the resident’s clinical record by licensed personnel… in accordance with state law and facility policy. The facility failed to ensure Resident 1’s medical records were not falsified by staff when RT 3 documented respiratory assessment and treatments after the resident had expired on 7/30/24 at 3:47 pm. On 7/30/24 at 4:32 pm, RT 3 acting as an employee and agent of the facility, knowingly and willfully falsified the medical records of Resident 1 when he documented treatments of: assess and suction for retained or increased secretions (mucus or fluids); and chest physiotherapy while awake. As a result, the facility documented inaccurately in Resident 1’s RAR. The above facts indicate that there was a willful material falsification in the medical records for Resident 1.