Health inspection·May 11, 2023

Health and Safety code: 1424(f)(2) - WMF (f) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) “Willful material falsification.” As used in this section, means any entry in the patient 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 decubitus 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. F842 42CFR §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized On 4/17/2023, an unannounced visit was conducted to the facility to investigate a complaint about Resident Rights and Falsification of Records. The facility failed to ensure Resident 1’s medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented. Social Services Assistant 1 (SSA 1) signed Resident 1’s Inventory of Personal Effects (belongings list) for Family Member 1 (FM 1). As a result, Resident 1’s clinical record had inaccurate documentation and placed the resident at risk for unaccounted and lost personal property. A review of Resident 1’s Face Sheet (Admission Record) indicated the facility admitted the 78-year-old female resident on 12/4/2018, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow to the brain), hemiplegia (one-sided muscle paralysis or weakness), and benign neoplasm of cerebral meninges (a tumor that forms in the layers of tissue that covers the brain and spinal cord). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 2/17/2023, indicated the resident’s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact. A review of Resident 1’s Social Services Assessment, dated 2/17/2023, indicated the resident was alert and oriented and could make decisions but allowed FM 1 to make decisions for her. A review of Resident 1’s Inventory of Personal Effects, dated 11/25/2021, indicated some resident’s belongings were listed. The signature section for the resident or the resident’s responsible party was signed resembling FM 1’s signature. Below the section for the resident or representative was the section for the facility staff to sign and SSA 1 signed and dated the form on 11/25/2023. On 4/19/2023 at 11:23 a.m., during an interview with the Social Services Director (SSD) and concurrent review of Resident 1’s Inventory of Personal Effects, dated 11/25/2021, SSD stated SSA 1 admitted to signing the form for FM 1. On 4/19/2023 at 12:53 p.m., during a telephone interview, SSA 1 acknowledged she completed the form and signed it for FM 1 to complete the form instead of waiting for FM 1 to come to the facility and sign it. A review of the facility’s policy and procedure titled, “Personal Conduct,” dated 1/19/2023, indicated that willful misconduct, gross negligence, falsifying records, giving false information, or withholding information from anyone authorized and responsible to have such information, misuse of confidential health or facility information, obtaining employment, promotion or fringe benefits under false pretense will not be tolerated. The facility failed to ensure Resident 1’s medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented. SSA 1 signed Resident 1’s Inventory of Personal Effects for FM 1. As a result, Resident 1’s clinical record had inaccurate documentation and placed the resident at risk for unaccounted and lost personal property. The above violations had a direct relationship to the health, safety, or security of Resident 1.