RALEIGH, NC - Universal Health Care/North Raleigh faced federal citations during a June 2024 inspection after surveyors documented systematic failures in maintaining accurate medical records, affecting the majority of residents whose charts were reviewed during the investigation.
Widespread Documentation Failures Discovered
Federal inspectors identified significant deficiencies in medical record-keeping practices at the 5201 Clarks Fork Drive facility, finding that staff failed to maintain complete and accurate documentation for four out of six sampled residents. The violations centered on critical aspects of patient care, including medication administration, treatment delivery, enteral feeding schedules, and weight monitoring—all essential components of resident health tracking.
Medical records serve as the primary communication tool among healthcare team members and provide the legal documentation of care delivered. When these records contain inaccuracies or omissions, the consequences extend beyond paperwork issues. Incomplete medication documentation can lead to dangerous double-dosing or missed doses, while inaccurate treatment records may result in wound care delays or inappropriate interventions. These documentation failures create gaps in the chain of care that can directly impact patient outcomes.
Critical Gaps in Nutritional Monitoring
The inspection revealed particularly concerning deficiencies in one resident's medical record related to nutritional care—a finding that exposed broader systemic issues within the facility's oversight structure. According to the inspection report, documentation problems included inaccurate records of enteral feedings and weight measurements, both critical metrics for patients requiring intensive nutritional support.
Weight monitoring serves as a fundamental indicator of nutritional status and overall health stability in nursing home residents. Regular, accurate weight measurements allow healthcare providers to detect early signs of malnutrition, dehydration, or disease progression. For residents receiving tube feedings, precise documentation of feeding administration ensures they receive prescribed caloric intake necessary for healing wounds, maintaining immune function, and preventing further health deterioration.
The facility's Administrator acknowledged during the investigation that she had delegated responsibility for monitoring residents with pressure ulcers and those at nutritional risk to the Assistant Director of Nursing (ADON). The Administrator stated she "had trusted the ADON to work with the Registered Dietitian to make sure the facility was compliant with monitoring weights and nutritional requirements."
Breakdown in Quality Oversight Systems
The inspection uncovered that despite holding Quality Assurance and Performance Improvement (QAPI) meetings on June 25, 2024, and July 30, 2024, the facility's oversight mechanisms failed to detect or correct the documentation deficiencies. The Administrator confirmed that during these meetings, the ADON was responsible for presenting information about residents with pressure ulcers and those at nutritional risk to ensure regulatory compliance.
This breakdown in the facility's quality assurance process represents a significant systemic failure. QAPI programs are designed to continuously monitor care quality, identify problems, and implement corrective actions before residents experience harm. When these systems rely on incomplete or inaccurate data—as occurred at Universal Health Care/North Raleigh—they cannot fulfill their protective function.
Federal regulations require nursing homes to maintain clinical records that are complete, accurately documented, readily accessible, and systematically organized. These standards exist because medical records directly influence clinical decision-making. A physician reviewing a chart with missing weight data may fail to recognize malnutrition, while a nurse relying on incomplete medication records may inadvertently administer a duplicate dose.
Medical Implications of Documentation Failures
The violations documented at this facility create multiple pathways for potential patient harm. For residents with pressure ulcers, inadequate nutritional intake can impair wound healing, increase infection risk, and prolong recovery times. Protein and calorie requirements increase significantly for wound healing—patients with pressure injuries may need 30-35 calories per kilogram of body weight daily, along with 1.25-1.5 grams of protein per kilogram.
When weight monitoring and feeding documentation are incomplete, healthcare providers lack the data necessary to assess whether residents are receiving adequate nutrition to support healing. This becomes particularly critical for residents receiving enteral nutrition, who depend entirely on prescribed feeding regimens to meet their nutritional needs.
Treatment documentation serves equally important functions. For wound care specifically, accurate records allow providers to track healing progress, identify infections early, and adjust treatment protocols based on response. Missing or inaccurate treatment documentation can result in delayed recognition of complications, inappropriate continuation of ineffective therapies, or premature discontinuation of beneficial treatments.
Additional Issues Identified
Beyond the primary violations, the inspection documented deficiencies affecting medication administration records for multiple residents. These documentation failures extended across various aspects of pharmaceutical care, creating additional risks for medication errors and adverse drug events in a population already vulnerable due to age and multiple chronic conditions.
The facility received a "minimal harm or potential for actual harm" citation level, indicating that while the documentation failures had not yet resulted in documented patient injuries at the time of inspection, the potential for harm existed. Federal surveyors determined that "some" residents were affected by these deficiencies, suggesting the problems extended beyond isolated incidents to represent patterns in facility operations.
Universal Health Care/North Raleigh must submit a plan of correction addressing how the facility will ensure accurate and complete medical record documentation going forward, including specific measures to strengthen oversight of nutritional monitoring and treatment documentation systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Universal Health Care/north Raleigh from 2024-06-06 including all violations, facility responses, and corrective action plans.
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