Other·November 9, 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 9/29/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a focused infection control survey. The facility failed to ensure Registered Nurse 1 (RN 1) did not falsify Resident 6’s medical records to indicate that RN 1 provided a peripherally inserted central catheter line (PICC line - a long, flexible catheter [thin tube] that's put into a vein) dressing change on 9/25/2023 as ordered by the physician every seven (7) days or as needed. As a result, Resident 6’s medical record had inaccurate information that falsely reflected the condition of Resident 6, or the care or services provided. This increased the risk of staff confusion about Resident 6’s condition, the care and services provided and placed Resident 6 at increased risk for infection from Resident 6’s PICC line. A review of Resident 6’s Admission Record indicated the facility admitted Resident 6 on 9/17/2023 with diagnoses including sepsis (the body's extreme response to an infection), enterocolitis (inflammation of the intestine) due to clostridium difficile (C. diff- is a germ that causes diarrhea), and low blood pressure. A review of Resident 6’s Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/21/2023, indicated that Resident 6 had intact cognition (ability to think and make decisions). The MDS further indicated that Resident 6 was receiving intravenous (IV- into a vein) medications. A review of the Physician’s Order for Resident 6, dated 9/17/2023, indicated Resident 6 had an order for PICC line dressing changes as needed if wet, loose, or soiled; and to change injection caps (caps used to cover the ports [access points] of a PICC line) to each lumen (line) with each dressing change and every dayshift (7:00 a.m. to 3:00 p.m.) every seven days. A review of Resident 6’s IV Administration Report for the month of 9/2023, indicated that on 9/25/2023, RN 1 changed Resident 6’s PICC transparent (clear) dressing. During a concurrent observation and interview on 9/28/2023 at 1:28 p.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 6’s left upper arm PICC line was observed. LVN 2 stated that Resident 6’s PICC line dressing had a date of 9/15/2023, which indicated that it was last changed by facility staff on 9/15/2023. LVN 2 stated that PICC line care and services are the responsibility of the registered nurses. During a concurrent interview and record review on 9/29/2023 at 2:55 p.m. with RN 1, Resident 6’s IV Administration Report for month of 9/2023 was reviewed. RN 1 stated that the IV Administration Report for Resident 6 for 9/2023 indicated that Resident 6’s left upper arm PICC line dressing was changed by RN 1 on 9/25/2023. RN 1 stated that she did not change Resident 6’s left upper arm PICC line dressing on 9/25/2023. RN 1 stated that she should not have signed in the IV Administration Record that she changed Resident 6’s left upper arm PICC line dressing since she did not change it. During a concurrent interview and record review on 9/28/2023 at 2:01 p.m., with the Nurse Consultant (NC), Resident 6’s IV Administration Record for month of 9/2023 was reviewed. NC stated that a PICC line dressing should be changed every seven days. When asked, what does the written date on the PICC line dressing mean, NC stated that it meant that the dressing was changed on that day. NC indicated that if the written date on Resident 6’s PICC line dressing was 9/15/2023, it meant that Resident 6’s PICC line dressing was changed prior to Resident 6’s admission to the facility on 9/17/2023. NC stated that RN 1 should not document that the PICC line dressing was changed if it was not done. NC stated that if a PICC line dressing was not changed per policy, the affected residents would be at risk for infection. A review of the facility’s policy and procedure titled “Charting and Documentation” last revised on 1/2023, last reviewed by the facility on 2/1/2023, indicated that “the purpose of the procedure is to provide a complete account of the resident’s care, treatment, response to care, signs, symptoms… as well as the progress of the resident’s care.” A review of the facility’s policy and procedure titled “Central Venous Catheter (CVC - long, flexible tube inserted into a vein used to receive medications, fluids or blood for emergency or long-term treatment, types include PICC lines and ports) Dressing Changes” last revised on 4/2016, last reviewed by the facility on 2/1/2023, indicated that “the purpose of the procedure is to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. The policy further indicated to change transparent semi-permeable membrane dressing at least every five to seven days and as needed.” The facility failed to ensure RN 1 did not falsify Resident 6’s medical records to indicate that RN 1 provided a PICC line dressing change on 9/25/2023 as ordered by the physician every seven days or as needed. As a result, Resident 6’s medical record had inaccurate information that falsely reflected the condition of Resident 6, or the care or services provided. This increased the risk of staff confusion about Resident 6’s condition, the care and services provided and placed Resident 6 at increased risk for infection from Resident 6’s PICC line. The above facts indicate there was a willful material falsification in the medical records for Resident 6.