Other·October 27, 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. On 9/8/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care and resident abuse. The facility failed to ensure Registered Nurse 1 (RN 1) did not falsify Resident 2’s medical records to indicate that RN1 provided a peripherally inserted central catheter (PICC line - a long, flexible catheter [thin tube] used to access the large veins om the chest) dressing change as ordered by the physician every seven [7] days or as needed. As a result, Resident 2’s medical record had inaccurate information that falsely reflected the condition of the resident, or the care or services provided. This increased the risk of staff confusion about Resident 2’s condition, the care and services provided, and placed Resident 2 at increased risk for infection from Resident 2’s PICC line. A review of Resident 2’s Admission Record indicated the facility admitted Resident 2 on 8/24/2023 with diagnoses including cellulitis (infection of the skin) of right lower leg and osteoarthritis (flexible tissue at the ends of the bones wears down, causing pain and stiffness). A review of Resident 2’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/2/2023, indicated Resident 2 was able to communicate, remember, and make decisions. The MDS further indicated Resident 2 was receiving intravenous (IV - into a vein) medications. A review of the Physician’s Order for Resident 2, dated 8/25/2023, indicated Resident 2 had an order for PICC transparent (clear) dressing change per sterile technique (use of practice that restricts germs in the environment and prevents contamination during resident care) on admission and every seven days (during the day shift [from 7:00 a.m. to 3:00 p.m.]) for IV site maintenance. A review of Resident 2’s Care plan, dated 9/9/2023, developed due to Resident 2 having a PICC line on the right upper arm indicated Resident 2 was at risk for infection and or complications related to IV access and medication administration. A review of Resident 2’s IV Administration Record for the month of 9/2023, indicated that on 9/1/2023, RN 1 changed Resident 2’s PICC transparent dressing. During a concurrent observation and interview on 9/8/2023 at 2:59 p.m., Resident 2’s right upper arm had multiple layers of tape over the PICC dressing. Resident 2 stated he was receiving IV antibiotic (medication used in treatment and prevention of infection) for the wounds on his legs. Resident 2 stated the PICC line was inserted in the hospital. Resident 2 stated the licensed nurses had not changed his PICC line dressing since he was first admitted to the facility approximately two (2) weeks ago. Resident 2 stated the licensed nurses were just applying tape over his PICC line dressing. During a concurrent observation and interview on 9/8/2023 at 3:24 p.m. with RN 1, Resident 2’s right upper arm PICC line was observed. RN 1 stated Resident 2’s PICC line dressing looked old, and he was not able to read the date on the dressing to establish when it was last changed. RN 1 stated the only part of the date he could read from Resident 2’s PICC line indicated “August” but was unable to read the day and year. RN 1 stated the PICC line dressing should be changed every seven days. During a concurrent interview and record review on 9/8/2023 at 3:28 p.m. with RN 1, Resident 2’s IV Administration Record for month of 9/2023 was reviewed. RN 1 stated the IV Administration Report indicated he (RN 1) changed Resident 2’s right upper arm PICC line dressing on 9/1/2023. RN 1 stated he did not change Resident 2’s PICC line dressing on 9/1/2023. RN 1 stated he should not have signed the IV Administration Record reflecting he changed Resident 2’s PICC line dressing on 9/1/2023 since he did not change it. RN 1 did not explain the reason for documenting the dressing change. During a concurrent interview and record review on 9/8/2023 at 3:30 p.m., with Assistant Director of Nursing (ADON), Resident 2’s IV Administration Record for month of 9/2023 was reviewed. ADON stated that a PICC line dressing should be changed every seven days. ADON stated that RN 1 should not document that the PICC line dressing was changed if it was not done. ADON stated that if a PICC line dressing was not changed per physician’s orders, residents would be at risk for infection. A review of the facility’s policy and procedure titled, “Documentation in Medical Record” last reviewed on 12/19/2022 indicated that each resident’s medical record shall contain a representation of their experiences of the resident. The policy further indicated that documentation shall be factual, and that false information shall not be documented. A review of the facility’s policy and procedure titled “PICC dressing changed” last reviewed on 7/12/2023, indicated that a transparent dressing is the preferred dressing. Dressing changes using transparent dressings are performed: 1. Upon admission (if not dated or site is not visible for assessment) 2. At least weekly 3. If the integrity (quality) of the dressing has been compromised (wet, loose or soiled). Further review of the facility’s policy and procedure titled “PICC dressing changed” last reviewed on 7/12/2023, indicated upon completion of the PICC dressing change, the licensed nurses (Registered Nurses and IV Certified Licensed Vocational Nurses) must document in the medical record, but is not limited to: 1. Date and Time 2. Site assessment (including integrity of transparent dressing) 3. Length of external catheter 4. Resident response to procedure and/or medication 5. Resident teaching The facility failed to ensure RN 1 did not falsify Resident 2’s medical records to indicate that RN1 provided a PICC line dressing change as ordered by the physician every seven [7] days or as needed. As a result, Resident 2’s medical record had inaccurate information that falsely reflected the condition of the resident, or the care or services provided. This increased the risk of staff confusion about Resident 2’s condition, the care and services provided, and placed Resident 2 at increased risk for infection from Resident 2’s PICC line. The above facts indicate there was a willful material falsification in the medical records for Resident 2.