Other·December 28, 2023

Health and Safety code 1424(f)(1) & (f)(2) - Willful Material Falsification (WMF) (f)(1) 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 10/26/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility-reported incident (FRI) about quality of care. The facility failed to maintain accurate medical records when Licensed Vocational Nurse 1 (LVN 1) knowingly and willfully falsified the medical record of Resident 1. LVN 1 falsely documented on Resident 1’s medical record indicating he measured Resident 1’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions) during the 11:00 p.m. to 7:00 a.m. nursing shift on the night of 10/25/2023 to the morning of 10/26/2023 when Resident 1 was not in the facility. As a result, the medical record of Resident 1 had inaccurate information and falsely reflected care or services provided. In this case, LVN 1 falsified the measurement of vital signs to Resident 1. A review of the Resident 1's Admission Record indicated the resident was readmitted to the facility on 4/3/2023 with diagnoses including aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (or stroke, disrupted blood supply and restricted oxygen supply to the brain) and type 2 diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated). A review of Resident 1's Nursing Progress Notes dated 10/26/2023, timed at 7:41 a.m., indicated Resident 1 left the facility (no time specified) without notifying the staff and ended up at General Acute Care Hospital 1 (GACH 1) and would be discharged back to the facility during 7:00 a.m. to 3:00 p.m. shift (10/26/2023). A review of Resident 1's Interdisciplinary Team (IDT) Care Conference Progress Notes, dated 10/26/2023, timed at 2:00 p.m., indicated GACH 1 called the facility informing them that law enforcement had picked up Resident 1 and took him to GACH 1. The IDT Care Conference Progress Note indicated the facility's surveillance video was checked, and Resident 1 left on 10/25/2023 at 9:31 p.m. A review of Resident 1's Medication Administration Record (MAR) for 10/25/2023 11:00 p.m. to 7:00 a.m. shift (no specific time documented) indicated Resident 1's blood pressure was 130/82 millimeters of mercury (mmHg – unit of measure), the temperature was 97.9 degrees Fahrenheit (°F), the heart rate was 86 beats per minute (bpm), the respiratory rate was 18 breaths per minute, and the oxygen saturation (measures how much oxygen is circulating in your blood) was 98%. On 10/31/2023 at 1:55 p.m. during an interview with the Director of Nursing (DON) and concurrent review of Resident 1 MAR for 10/25/2023 during the 11:00 p.m. to 7 a.m. shift, the DON stated LVN 1 documented and signed Resident 1’s vital signs. On 10/31/2023 at 2:02 p.m., during an interview, LVN 1 confirmed he documented Resident 1's vital signs during the 11:00 p.m. to 7:00 a.m. shift and acknowledged he learned at around 3:45 a.m. (on 10/26/2023) that Resident 1 was not in the facility but was at GACH 1. LVN 1 stated he copied and pasted Resident 1's vital signs taken during the 3:00 p.m. to 11:00 p.m. shift (previous shift). LVN 1 stated he did not obtain Resident 1's vital signs during the 3:00 p.m. to 11:00 p.m. shift and since Resident 1 was not in the facility during the 11:00 p.m. to 7:00 a.m. shift, he could not have possibly taken Resident 1's vital signs. LVN 1 stated he needed to document vital signs because he was not supposed to leave blanks on the MAR. LVN 1 stated the facility did not have a policy to prevent documenting vital signs taken during a previous shift. During an interview with the DON on 10/31/2023 at 4:15 p.m., the DON stated staff are not to copy vital signs or any other type of documentation. Staff are only to document interventions that they have done. The facility's policy and procedure titled "Documentation in Medical Record", with a revised date of 12/19/2022, indicated each resident’s medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident ' s progress. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident ' s medical record in accordance with state law and facility's policy. The facility failed to maintain accurate medical records when LVN 1 knowingly and willfully falsified the medical record of Resident 1. LVN 1 falsely documented on Resident 1’s medical record indicating he measured Resident 1’s vital signs during the 11:00 p.m. to 7:00 a.m. nursing shift on the night of 10/25/2023 to the morning of 10/26/2023 when Resident 1 was not in the facility. As a result, the medical record of Resident 1 had inaccurate information and falsely reflected care or services provided. In this case, LVN 1 falsified the measurement of vital signs to Resident 1. The above facts indicate there was willful material falsification in the medical record of Resident 1.