Health inspection·June 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. 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 4/17/2023, an unannounced visit was conducted to the facility to investigate a complaint about Quality of Care. The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and practices for Resident 1 when Treatment Nurse 1 (TN 1) willfully falsified entries (when a staff knowingly documents that a certain care or services was provided to the resident despite not providing those care or services) in Resident 1’s Treatment Administration Record (TAR - a record of nursing treatment / care to wounds, devices, and skin) indicating that TN 1 provided urostomy (a surgically-created stoma [opening] in the lower abdomen wall through which urine passes) site treatment and replaced the urostomy bag on 4/1/2023, 4/5/2023, 4/12/2023, 4/15/2023, 4/22/2023, and 4/29/2023, when she did not. As a result, Resident 1’s clinical record had inaccurate information and had the potential to result in infection and other complications from lack of care on the urostomy site. A review of Resident 1’s Admission Record indicated the facility admitted the 84-year-old male resident on 5/24/2019 and readmitted the resident on 10/4/2020 with diagnoses that included end stage renal disease (ESRD, a medical condition in which the kidneys do not function properly) malignant neoplasm (cancerous tumor [a solid mass of tissue that forms when abnormal cells group together] of the bladder, acquired absence of other parts of the urinary tract (system to remove urine from the body). A review of Resident 1’s History and Physical, dated 1/19/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – standardized assessment and care-screening tool) dated 4/5/2023, indicated the resident had the ability to understand others and had the ability to make herself understood. Resident 1 had an ostomy (a surgically created stoma in the abdomen wall). A review of the Physician’s Orders for Resident 1, dated 12/21/2022, indicated to cleanse the urostomy sire with normal saline (NS, a cleaning solution), pat dry, and apply urostomy bag (a special bag that is attached to the skin around the stoma and is used to collect urine) every week and as needed for loss of integrity (leaking of collection bag), every day shift every Wednesday and Saturday. On 5/9/2023, at 12:45 p.m., during an observation of Resident 1 in her room and concurrent interview, Resident 1 stated she had a urostomy covered with a collection bag. The collection bag was on the right lower abdomen. Resident 1 stated the collection bag must be changed routinely, when the skin gets irritated or if there is a leak. Resident 1 stated there was an incident (unable to recall exact date) where TN 1 refused to change the urostomy collection bag when it was leaking because TN 1 said she was busy. Resident 1 stated that since then, for about three months, she (Resident 1) would not allow TN 1 to provide urostomy care. During an interview on 5/9/2023, at 4:30 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was familiar with Resident 1 and knew her well. LVN 2 stated Resident 1 only wants Treatment Nurse 2 (TN 2) to provide the resident’s urostomy care and will not allow TN 1 to provide urostomy care. On 5/10/2023 at 1:45 p.m., during an interview with TN 2 and concurrent review of the TAR for 4/2023, TN 2 explained Resident 1 gets urostomy site treatment each week on Wednesday and Saturday and as needed. TN 2 stated the TAR indicates TN 1 as having provided Resident 1 with urostomy site care on 4/1/2023, 4/5/2023, 4/12/2023, 4/15/2023, 4/22/2023, and 4/29/2023. On 5/12/2023 at 1:35 p.m., during an interview with TN 1 and concurrent review of the TAR for 4/2023, TN 1 stated she has not provided Resident 1 with urostomy site care for “about six months.” TN 1 stated she did not provide urostomy care to Resident 1 on 4/1/2023, 4/5/2023, 4/12/2023, 4/15/2023, 4/22/2023, and 4/29/2023, and she may have “accidentally” documented on Resident 1’s TAR. On 5/15/2023 at 1:05 p.m., during an interview with the Director of Nursing (DON) and a concurrent review on the facility’s policies on Medication and TAR Documentation, the DON stated TN 1 did not follow the policies. A review of the facility’s policy and procedure titled, “Medication and Treatment Administration Record,” last reviewed 2/2023, indicated medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication and / or treatment is provided. administered as prescribed. The nurse that administers the medication or treatment is to record his/her initials in the appropriate box on the MAR (medication administration record) and / or TAR. When a resident refuses a routine medication or treatment or such is withheld, the explanation is to be recorded in accordance with the facilities electronic medical record system. A review of the facility’s policy and procedure titled, “Documentation,” last reviewed 2/2023, indicated nursing personnel will maintain complete and accurate documentation, in accordance with State and Federal Guidelines. All documentation will be completed as required for each resident. Documentation entries will be factual and specific. The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and practices for Resident 1 when TN 1 willfully falsified entries in Resident 1’s Treatment Administration Record indicating TN 1 provided urostomy site treatment and replaced the urostomy bag on 4/1/2023, 4/5/2023, 4/12/2023, 4/15/2023, 4/22/2023, and 4/29/2023, when she did not. As a result, Resident 1’s clinical record had inaccurate information and had the potential to result in infection and other complications from lack of care on the urostomy site. The above violations had a direct relationship to the health, safety, or security of Resident 1.