Health inspection·December 16, 2024

F842 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §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 HSC 1424 (f) (f)(1) A willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the resident's health care record pertaining to the administration of medication,, or treatments ordered for the patient, or pertaining to services for the prevention of treatment of pressure 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 services provided. (3) As used in this section, "willful material omission" means the willful failure to record any untoward event that has affected the health, safety, or security of the specific resident, and that was omitted with the knowledge that the records falsely reflect the condition of the resident, or the care of services provided. 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/6/2024, the California Department of Public Health (CDPH) received a complaint alleging residents were not receiving Restorative Nurse Assistant ([RNA] nursing aid program that helps residents maintain their function and mobility) services as ordered because there was only one RNA for the entire facility with over 30 residents who had orders to receive RNA services. On 11/20/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined RNA 1 documented she provided RNA services to Resident 1 when services were not provided. The facility failed to: 1. Ensure RNA 1 did not falsify records to indicate Resident 1 received RNA services that were not provided to her. 2. Follow their policy and procedure (P/P), titled, "Charting and Documentation," revised 7/2017, that indicated documentation in the medical record would be accurate. This deficient practice resulted in RNA 1 documenting Resident 1 was provided seven minutes of passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises to her bilateral lower extremities ([BLE] both of her leg) as well as an application of a splint (a rigid material or apparatus used to support an impaired joint) to the resident's right knee on 11/22/2024 at 2:59 p.m., when those services were not provided. This deficient practice placed Resident 1 at risk for development of contractures (loss of motion of a joint) further decline in mobility and physical functioning. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a11/22/2024 82 year-old female, was admitted to the facility on 6/7/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or an inability to move on one side of the body) and dementia (a progressive state of decline in mental abilities). A review of Resident 1's History and Physical (H&P) dated, 6/13/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2024, indicated Resident 1's cognition was severely impaired, and she sometimes had the ability to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for rolling left to right in bed, bed to chair transfers, chair to bed transfers, and personal hygiene. The MDS indicated Resident 1 had functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) in one upper (shoulder, elbow, wrist, and hand) and one lower (hip, knee, ankle, and foot) extremity. The MDS indicated Resident 1 did not walk during the assessment period. A review of Resident 2's Physician's Orders Report dated 11/20/2024, indicated Resident 1 had the following physician's orders: 1. An order dated 10/31/2024 for RNA to perform PROM exercises to Resident 1's right LE five times a week, as tolerated. 2. An order dated 10/31/2024 for RNA to apply a splint to Resident 1's right knee three to six hours daily, five times a week, as tolerated. During an observation on 11/22/2024 at 8:30 a.m., 11:52 a.m., and 12:55 p.m., Resident 1 was observed in her room, in bed and her knee splint was observed on top of her nightstand. During an observation on 11/22/2024 at 2:25 p.m., and 3:01 p.m., Resident 1 was observed sitting in a wheelchair in the facility's front lobby, without a splint on her right knee. During a telephone interview on 11/22/2024 at 9:16 a.m. Resident 1's Family Member (FM 1), stated he was concerned that Resident 1 was not receiving RNA services which included ROM exercises and a right knee splint application. FM 1 stated when he visited Resident 1, he would never see the RNA perform ROM exercises on Resident 1, nor would he see Resident 1 wearing her right knee splint. FM 1 stated he brought this to the facility's attention several times, and the facility stated per documentation Resident 1 was in fact receiving RNA services as ordered. During a concurrent interview and record review on 11/22/2024 at 3:40 p.m., with RNA 1, Resident 1's Task Report dated 11/22/2024 was reviewed. The Task Report indicated Resident 1 received seven minutes of PROM to both her lower extremities (BLE) on 11/22/2024 at 2:59 p.m. RNA 1 stated on 11/22/2024, she documented she performed PROM to Resident 1's BLE at 2:59 p.m. but she must have accidentally documented she provided those services by mistake because she did not perform PROM exercises to Resident 1. RNA 1 stated she was the only RNA on the skilled side of the facility to care for over 30 residents who required RNA services. RNA 1 stated that in addition to her providing RNA services, she also was assisting the Certified Nursing Assistants (CNAs) with transfers, passing snacks to residents, and helping to change and reposition residents. During a concurrent interview and record review on 11/22/2024 at 3:45 p.m. with RNA 1, Resident 1's Task Report dated 11/22/2024 was reviewed. The Task Report indicated RNA 1 applied Resident 1's splint to the resident's right knee on 11/22/2024 at 2:59 p.m. RNA 1 stated she documented she applied Resident 1's splint to her right knee but admitted she did not apply the splint. During an interview on 11/26/2024 at 1:01 p.m., the Director of Staff Development (DSD) stated it was not appropriate for RNA 1 to document in Resident 1's clinical record that RNA services were provided to Resident 1 if she (RNA 1) did not provide those services to Resident 1. The DSD stated the RNA's documentation must accurately reflect the care and/or services provided. During an interview on 11/26/2024 at 1:47 p.m., the Director of Nursing (DON), stated RNAs should not document that RNA services were provided when they (RNAs) had not actually provided the care to the resident. The DON stated missed RNA treatments could potentially cause a resident to experience a decline in overall function, mobility, and activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). A review of the facility's RNA Job Description dated 6/12/2009, indicated the RNA's duties and responsibilities include charting (documenting) appropriately. A review of the facility's P&P titled, "Charting and Documentation," revised 7/2017, indicated documentation in the medical record will be accurate. The facility failed to: 1. Ensure RNA 1 did not falsify records indicating Resident 1 received RNA services that were not provided to her. 2. Follow their P/P titled, "Charting and Documentation," revised 7/2017, that indicated documentation in the medical record will be accurate. This deficient practice resulted in RNA 1 documenting Resident 1 was provided seven minutes of PROM exercises to her BLE as well as an application of a splint to the resident's right knee on 11/22/2024 at 2:59 p.m., when those services were not provided. This deficient practice placed Resident 1 at risk for development of contractures, further decline in mobility and physical functioning. The above facts indicates there was a willful material falsification in the medical record of Resident 1.