LOS ANGELES, CA - Federal inspectors documented concerning patterns in medical record-keeping at University Park Healthcare Center after discovering identical vital sign readings across seven different residents.
Identical Vital Signs Raise Red Flags
During a February 13, 2025 inspection, Centers for Medicare & Medicaid Services surveyors identified a troubling pattern in the facility's medical records. Seven residents - identified in the report as Residents 77, 53, 341, 32, 62, 21, and 19 - had documented vital signs that were suspiciously identical across both the 3:00 PM-11:30 PM and 11:00 PM-7:30 AM shifts from February 8 through February 11, 2025.
The documentation showed readings such as blood pressure measurements of 127/74, temperatures of 97.1°F, pulse rates of 72, respiratory rates of 18, and oxygen saturation levels of 96% appearing across multiple residents' records during the same time periods. Medical professionals recognize that while vital signs can fall within normal ranges, having identical readings across multiple patients over consecutive days is statistically improbable.
Medical Significance of Accurate Vital Signs
Vital signs serve as fundamental indicators of a patient's physiological status and are critical for detecting changes in health conditions. Blood pressure readings help monitor cardiovascular health and medication effectiveness. Temperature measurements can indicate infection or other medical complications. Pulse rates reflect heart function, while respiratory rates and oxygen saturation levels are essential for assessing breathing and circulation.
For residents with complex medical conditions like those at University Park Healthcare Center - including diagnoses such as metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia - accurate vital sign monitoring becomes even more critical. These conditions can cause rapid changes in physiological status that require immediate medical attention.
Nursing Staff Protocols and Documentation Requirements
Healthcare facilities are required to maintain accurate medical records that reflect each resident's actual condition. Federal regulations mandate that nursing staff conduct routine resident checks at least once per eight-hour shift, with proper documentation of the time, identity of the person conducting the check, and any relevant findings.
The facility's own policy, titled "Routine Resident Checks," specifically requires nursing staff to document these routine checks including timing, staff identity, and outcomes. This policy directly contradicted statements made by facility leadership during the inspection.
Staff Responses During Investigation
When confronted with the documentation patterns, the facility's Director of Nursing acknowledged that the vital sign records were identical across the seven residents but declined to characterize this as falsification. During the interview on February 12, 2025, the Director stated she "could not consider the vital sign documentation for Resident 77, 53, 341, 32, 62, 21, and 19 as falsification of records because it was not her assessment."
However, the Director could not provide written policies specifying documentation frequency requirements for skilled nursing notes, despite claiming daily documentation was sufficient rather than shift-based recording.
Licensed Vocational Nurse 4, who worked the 11:00 PM-7:30 AM shifts during the questioned period, maintained that he personally took all vital signs and that his documentation was accurate. When asked to explain how readings from his overnight shifts matched those from the evening shifts, LVN 4 could not provide an explanation.
Regulatory Violations and Standards
The inspection resulted in a violation under F842, which addresses the facility's obligation to maintain accurate and complete medical records. The violation was classified as "minimal harm or potential for actual harm" affecting "few" residents.
Federal nursing home regulations require that all clinical records accurately reflect each resident's condition and the care provided. This includes vital signs, which must represent actual measurements taken during specified times rather than estimated or copied values.
Professional nursing standards emphasize that each vital sign measurement must be individually obtained and recorded to ensure accurate monitoring of patient status. Healthcare facilities must implement systems that prevent documentation errors and ensure staff compliance with measurement protocols.
Potential Health Consequences
Inaccurate vital sign documentation can have serious implications for resident care. Healthcare providers rely on these measurements to make critical decisions about medication dosages, treatment modifications, and emergency interventions. When vital signs are not accurately recorded, medical staff may miss early warning signs of deteriorating health conditions.
For elderly residents with multiple chronic conditions, even small changes in vital signs can indicate significant health events. Failure to detect and respond to these changes promptly can result in preventable complications, hospitalizations, or adverse outcomes.
Industry Context and Prevention
Healthcare facilities typically implement multiple safeguards to ensure accurate documentation, including electronic health record systems with timestamp verification, supervisory review processes, and staff training on proper measurement techniques. Many facilities also use automated vital sign equipment that directly uploads readings to patient records, reducing opportunities for documentation errors.
Best practices in nursing home care emphasize the importance of individualized resident monitoring, with vital signs taken according to each resident's specific care plan and medical needs rather than routine batch processing that might lead to standardized or copied entries.
The violation at University Park Healthcare Center highlights the ongoing importance of federal oversight in ensuring nursing homes maintain accurate medical records that truly reflect resident conditions and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Healthcare Center from 2025-02-13 including all violations, facility responses, and corrective action plans.
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