Other·February 28, 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 1/19/2023, an unannounced visit was conducted to the facility to investigate a complaint regarding quality of care/treatment. The facility failed to maintain medical records in accordance with standards and practices and ensure the records did not falsely reflect the care and services provided to Resident 1. On 1/6/2023, Licensed Vocational Nurse (LVN 1) documented in Resident 1’s medication administration record (MAR) administering three medications scheduled at 5 p.m. despite not giving the resident the three medications. As a result, Resident 1’s clinical record had inaccurate documentation indicating medications the resident did not receive. A review of Resident 1's Admission Record (Face Sheet) indicated an admission dated 12/21/2021 and readmission on 11/3/2022 with diagnosis including end stage renal disease (ESRD – final stage of chronic kidney disease) and essential hypertension (high blood pressure, a condition in which the force of the blood against the artery walls is too high). A review of Resident 1’s History and Physical dated 11/4/2022 indicated the resident had the capacity to understand and make decisions. A review of Resident 1's MAR dated 1/6/2023 indicated Licensed Vocational Nurse 1 (LVN 1) documented the following medications given by mouth at 5 p.m.: 1. Calcium Carbonate (treats digestive disorder) 500 milligrams (mg – a unit of measure) for gastroesophageal reflux disease (GERD – a digestive disorder) four tablets. 2. Dicyclomine HCL (treats inflammatory bowel disease) 40 mg. 3. Ascorbic acid (vitamin c supplement for wound healing) 500 mg six tablets. On 1/19/2023 at 7 p.m., during an interview with LVN 1 and concurrent review of Resident 1’s MAR, LVN 1 stated she was the medication nurse for Resident 1 on 1/6/2023 during the 3 p.m. to 11 p.m. LVN 1 stated she did not administer Resident 1 the three medications scheduled at 5 p.m. but documented their administration because she assumed the medication nurse from the previous shift (7 a.m. to 3 p.m.) administered the 5 p.m. scheduled medications. On 1/23/2023 at 2:15 p.m., during an interview with LVN 2 and concurrent review of Resident 1’s MAR, LVN 2 stated she was the medication nurse for Resident 1 on 1/6/2023 during the 7 a.m. to 3 p.m. and did not administer the resident medications scheduled at 5 p.m. On 1/23/2023 at 3:40 p.m., during an interview, LVN 1 stated she knew she was not to document the administration of medications she did not give. On 1/23/2023 at 1:20 p.m., during an interview with the Director of Nursing (DON) and a review of Resident 1’s MAR for 1/6/2023, the DON stated LVN 1 violated the facility’s policies and procedures on medication administration. The DON stated a licensed nurses can only sign for medications they give and not given by another licensed nurse. A review of the facility's undated policy and procedures titled, "Med Pass," indicated "Prepare the med correctly, administer the med correctly, and chart the med pass correctly. A med error is a violation in medication regulation and/or current standard practice." The facility failed to maintain medical records in accordance with standards and practices and ensure the records did not falsely reflect the care and services provided to Resident 1. On 1/6/2023, LVN 1 documented in Resident 1’s MAR administering three medications scheduled at 5 p.m. despite not giving the resident the three medications. As a result, Resident 1’s clinical record had inaccurate documentation indicating medications the resident did not receive. The above violations had a direct relationship to the health, safety, or security of Residents 1.