Health inspection·July 19, 2024

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 6/5/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the revisit for its Annual Recertification Survey. The facility failed to maintain accurate medical records and failed to ensure Licensed Vocational Nurse 2 (LVN 2) did not falsify (to alter, make a false entry into a resident's medical record) the medication administration of Resident 408 by marking that polyethylene glycol 3350 powder (medication used to treat constipation [a bowel dysfunction that makes bowel movements infrequent or hard to pass]) was administered on 6/5/2024 for Resident 408. As a result of the investigation, CDPH determined that LVN 2 willfully falsified medical records pertaining to the administration of medication for Resident 408. A review of Resident 408's Admission Record indicated the facility initially admitted the resident on 11/30/2023 and readmitted the resident on 5/19/2024 with diagnoses including right hip dislocation (bones in the hip being pushed out of their usual place) and osteoarthritis (a condition that causes joints to become painful and stiff). A review of Resident 408's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/6/2024, indicated Resident 408's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 408 was dependent on staff for toileting hygiene, showering. The MDS indicated that Resident 408 needed extensive assistance from staff for mobility (movement) such as rolling from side to side in the bed, lying to sitting on side of bed, and sitting to standing. A review of Resident 408's Physician Order dated 5/19/2024 indicated to administer polyethylene glycol 3350 powder 17 gram (g - a unit of measurement) by mouth one time a day for bowel movement (BM), hold if loose BM (when your stools are loose and watery). On 6/5/2024 at 8:29 a.m., during a medication administration observation for Resident 408, observed LVN 2 not preparing and subsequently not administering polyethylene glycol 3350 power 17g to Resident 408. During a record review for Resident 408's Medication Administration Record (MAR) on 6/5/2024 at 3:00 p.m., the MAR indicated that LVN 2 administered polyethylene glycol 3350 powder to Resident 408 on 6/5/2024 at 9:00 a.m. During an interview on 6/5/2024 at 3:24 p.m. with LVN 2, LVN 2 stated that during Resident 408's morning medication administration on 6/5/2024 at 8:29 a.m., LVN 2 was aware that Residents 408's dose of polyethylene glycol 3350 powder 17g was not inside the medication cart. LVN 2 stated that LVN 2 signed Resident 408's MAR indicating that LVN 2 administered Resident 408's 9:00 a.m. dose of polyethylene glycol 3350 powder 17g with the intention of giving the medication at a later time. LVN 2 stated that LVN 2 then forgot to give polyethylene glycol 3350 17g to Resident 408. LVN 2 stated that it was not until 3:24 p.m. that LVN 2 remembered that Resident 408's dose of polyethylene glycol 3350 powder 17g was still not given. During an interview on 6/5/2024 at 4:57 p.m., with Registered Nurse Supervisor 1 (RN 1), RN 1 stated that it is unacceptable to mark a medication as being given to a resident before administering the medications to the residents. During an interview on 6/6/2024 at 2:12 p.m. with LVN 2, when LVN 2 was asked if LVN 2 documented willfully and falsely in the MAR for Resident 408's dose of polyethylene glycol 3350 powder 17g for 6/5/2024, for 9:00 a.m., LVN 2 stated "Yes, falsely". During an interview on 6/6/2024 at 2:31 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that if LVN 2 knew Resident 408's dose of polyethylene glycol 3350 powder 17g was not available in the medication cart and LVN 2 still documented as administering Resident 408's dose of polyethylene glycol 3350 powder 17g in MAR, then LVN 2 willfully falsified Resident 408's MAR. A review of the facility's policy and procedure (P&P) titled, "Medication Administration-General Guidelines", last reviewed on 1/11/2024, indicated that the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and then documented. A review of the facility's P&P titled, "Documentation Content of the Record Set", last reviewed on 1/11/2024, indicated that the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized. The facility failed to maintain accurate medical records and failed to ensure LVN 2 did not falsify the medication administration of Resident 408 by marking that polyethylene glycol 3350 powder was administered on 6/5/2024 for Resident 408. As a result of the investigation, CDPH determined that LVN 2 willfully falsified medical records pertaining to the administration of medication for Resident 408. The above facts indicate there was willful material falsification in the medical records of Resident 408.