Health inspection·October 25, 2022

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 8/17/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care/treatment and facility staffing. The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by not ensuring Respiratory Therapist (RT 1) did not willfully falsified entries in Resident 1's ventilator (a machine that assists with breathing) flow sheet (documentation of assessments for ventilator settings) for 8/9/2022 at 8:00 p.m. As a result, Resident 1’s clinical record had inaccurate documentation indicating care the resident did not receive. A review of Resident 1's Admission Record (Face Sheet) indicated an admission dated 6/4/2022 with diagnoses including hemiplegia (inability to move of one side of the body) and tracheostomy (opening created at front of the neck so a tube can be inserted into the windpipe to help you breathe). A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care-screening tool) dated 6/13/2022, indicated the resident had the ability to rarely/never make self-understood and rarely/never understand others. A review of the Physician's Orders for Resident 1 indicated the following ventilator orders: - Ventilator settings volume control ventilator mode (the settings for the ventilator machine specified for the resident) SIMV Set Tidal Volume: 500 set RR: 10 Set PEEP: +5 H2O Set PS: 8cmH2O O2 at 5L/min May titrate O2 L/in to maintain oxygen saturation at greater or equal to 92%. Apply ventilator: continuous - Ventilator settings volume control ventilator mode SIMV Set Tidal Volume: 500 set RR: 14 Set PEEP: 5cmH2O Set PS: 14cmH2O O2 at 5L/min May titrate O2 L/in to maintain oxygen saturation at greater or equal to 92%. Apply ventilator: continuous - Ventilator settings volume control ventilator mode SIMV Set Tidal Volume: 450 set RR: 18 Set PEEP: 5cmH2O Set PS: 14cmH2O O2 at 5L/min May titrate O2 L/in to maintain oxygen saturation at greater or equal to 92%. Apply ventilator: A review of Resident 1’s Continuous Ventilator Flow Sheet dated 8/9/2022 indicated ventilator settings and assessments documented on that date at 8:00 p.m. During an interview on 8/17/2022 at 8:25 p.m., the Respiratory Therapist (RT 1) stated she worked at the facility on 8/9/2022 and her scheduled shift was from 6:00 p.m. until 6:00 a.m. RT 1 verified her assignment included Resident 1. When asked about Resident 1’s assessment during her shift, RT 1 stated that she recorded all her assessments of Resident 1 on the ventilator flow sheet. RT 1 stated that the flow sheet assessment documentation would indicate that she saw the resident around 8:00 p.m. During a concurrent interview and record review on 9/8/2022 at 10:10 a.m., RT 1 verified that she handwrote and signed the assessment records and summary on Resident 1’s ventilator flow sheet dated 8/9/2022 timed at 8:00 p.m. When RT 1 was asked when she documented this information, she stated that she documented on either 8/17/2022 late night or 8/18/2022 early morning. RT 1 stated she willfully created this false documentation because she was nervous when she could not find her documentation for Resident 1 dated 8/9/2022. When asked if she filled out the resident’s ventilator flow sheet on 8/17/2022, but dated it as 8/9/2022, with intention of having it appear as if it was done on 8/9/2022, she stated yes. During an interview on 9/8/2022 at 12:35 p.m., the medical records staff (MR) stated she worked on 8/17/2022 and locked the medical records office door around 4:00 p.m. prior to leaving the facility. Resident 1’s medical chart was a close chart since resident had expired at the facility and all records were placed in a folder and inside the medical records office. During a concurrent interview and record review on 9/8/2022 at 1:20 p.m., RT 1 stated that she knew the medical records room was locked during night shift on 8/17/2022. RT 1 stated that she went into the medical records room on 8/18/2022 in the beginning of morning shift around 7:00 a.m. and placed Resident 1’s ventilator flow sheet dated 8/9/2022 inside the resident’s chart. RT 1 stated she did not notify any supervising staff about this incident. During a concurrent interview and record review on 9/8/2022 at 2:20 p.m., the Director of Nursing (DON) verified that Resident 1’s ventilator flow sheet was dated 8/9/2022. DON verified that the documentation dated 8/9/2022 at 8:00 p.m. did not indicate that this was a late entry documentation reflecting the correct date. The DON stated that a late entry would have indicated the date it was documented and reason for that late entry. A review of the facility's policy and procedure titled, "Charting and Documentation," undated, indicated, "All services provided to the resident, or any changes in the resident’s medical or mental condition, shall be documented in the resident’s medical records." A review of the facility’s policy and procedure titled, “Health information/Record Manual”, dated revised 5/3/2018, indicated “All entries shall be complete, concise, descriptive and accurate.” The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by not ensuring RT 1 did not willfully falsified entries in Resident 1's ventilator flow sheet for 8/9/2022 at 8:00 p.m. As a result, Resident 1’s clinical record had inaccurate documentation indicating care the resident did not receive. The above violations had a direct relationship to the health, safety, or security of Residents 1.