SANTA MONICA, CA - Federal inspectors discovered fraudulent documentation and significant wound care failures at Berkley East Healthcare Center during an April 2025 inspection, including falsified treatment records for a resident who had already been transferred to a hospital.
Falsified Treatment Documentation
The most serious violation involved falsified treatment records for a diabetic resident with multiple wounds. According to the inspection report, a Licensed Vocational Nurse documented that all skin treatments were administered to the resident on April 7, 2025. However, the resident had been transferred to General Acute Care Hospital on April 4, 2025, making the documented treatments impossible.
The Director of Nursing confirmed during interviews that the documentation was fraudulent, as the resident was not present at the facility when the treatments were allegedly administered. This type of false documentation violates federal regulations requiring accurate and complete medical records.
Fraudulent medical documentation poses serious risks to patient safety. When treatment records are falsified, it becomes impossible to track actual care provided, monitor healing progress, or ensure continuity of care. This can lead to missed treatments, medication errors, and compromised patient outcomes.
Comprehensive Wound Care Failures
The resident at the center of these violations had multiple serious medical conditions requiring careful wound management. The patient was admitted with surgical aftercare needs following circulatory system surgery, Type II diabetes mellitus, peripheral vascular disease, and chronic non-pressure ulcers on the right ankle.
Medical records showed the resident required treatment for three distinct wound sites: - Right dorsal foot arterial wound requiring daily cleansing and specialized dressing - Right femoral area incision site needing daily care - Right foot wound requiring topical antibiotics
Despite these complex medical needs, facility staff failed to arrange wound specialist consultation during the resident's entire stay. Treatment Nurse noted in documentation that the resident "was supposed to be seen by wound specialist today, but resident was not in the room."
Behavioral Issues Left Unaddressed
Inspectors found the resident had developed a pattern of removing his own wound dressings, stating the dressings were "itchy." This behavior left surgical sites and chronic wounds exposed to air and potential contamination. Despite staff awareness of this issue, no care plan was developed to address the behavior.
The Director of Nursing acknowledged that when residents remove wound dressings independently, it creates significant infection risk. Exposed wounds can become contaminated, and residents may scratch affected areas, causing bleeding and further complications.
For diabetic patients, proper wound care is especially critical. Diabetes impairs the body's ability to heal wounds and fight infections. Poor blood sugar control and compromised circulation make diabetic patients particularly vulnerable to serious complications from wound infections, including potential limb loss.
Missing Specialist Oversight
Federal regulations require nursing homes to provide appropriate wound care and arrange specialty consultations when needed. The facility's own policies stated that residents with skin integrity issues should receive wound assessment and consultation upon admission to validate treatment appropriateness.
The Treatment Nurse confirmed during interviews that the Wound Provider Specialist visits weekly but acknowledged the resident had not been evaluated since admission. This failure to obtain specialist consultation potentially delayed appropriate care modifications and healing assessment.
Documentation Standards Violated
The facility's policies require objective, complete, and accurate documentation. The falsified treatment records directly violated these standards and federal requirements for truthful medical documentation.
Accurate medical records serve multiple critical functions in healthcare settings. They track treatment effectiveness, ensure continuity of care between shifts, provide legal protection for both patients and facilities, and enable quality improvement initiatives.
Medical Consequences and Industry Standards
Proper wound management protocols require consistent monitoring, appropriate dressing materials, and specialist consultation for complex cases. When these standards are not met, residents face increased risks of infection, delayed healing, and potential complications requiring emergency medical intervention.
The combination of falsified documentation and inadequate wound care created multiple layers of risk for this vulnerable resident. Federal inspectors classified the violations as having potential for actual harm, recognizing the serious nature of compromised wound care for diabetic patients.
The facility was cited under federal Tag F686 for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing, and Tag F656 for inadequate care planning to address resident behaviors affecting medical treatment.
This case highlights the importance of accurate medical documentation, appropriate specialist consultation, and comprehensive care planning in nursing home settings, particularly for residents with complex medical conditions requiring specialized wound management protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Berkley East Convalescent Hosp from 2025-04-29 including all violations, facility responses, and corrective action plans.
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