POMONA, CA - State inspectors found that nurses at Inland Valley Care and Rehabilitation Center failed to properly document a resident's severe abdominal pain and breathing difficulties during a medical emergency in May 2025, potentially compromising the quality of care provided.
Critical Documentation Gaps During Medical Emergency
The inspection revealed significant lapses in medical record-keeping when a resident experienced a serious gastrointestinal crisis over a two-day period. The resident, who has psychosis and muscle atrophy, reported severe constipation, abdominal pain, and breathing difficulties that escalated to an 8 out of 10 pain level.
Despite multiple nurses assessing the resident's condition, crucial details were omitted from medical records. Registered Nurse 2 conducted a comprehensive assessment on May 6th, finding hypoactive bowel sounds, abdominal distension, and firmness, but failed to document these critical findings in the resident's medical record. The nurse later acknowledged that based on the assessment, the resident was experiencing severe pain.
Licensed Vocational Nurse 4 made similar documentation errors, stating: "LVN 4 forgot to document Resident 1's 8 out of 10 pain in Resident 1's MAR and document Resident 1 had coffee-ground emesis." Coffee-ground emesis can indicate serious gastrointestinal bleeding and represents a medical emergency requiring immediate attention.
Oxygen Administration Discrepancies
The documentation problems extended to respiratory care. When the resident complained of breathing difficulties on May 6th at 11:10 PM, LVN 4 increased the oxygen flow rate from 2 to 3.5 liters per minute via nasal cannula. However, the nurse documented only 3 liters per minute in the medical record, creating a discrepancy between actual care provided and recorded treatment.
This type of inaccurate documentation can have serious medical consequences. Oxygen saturation levels and flow rates are critical indicators that physicians use to assess respiratory status and adjust treatment plans. When documentation doesn't reflect actual conditions or treatments, it can lead to inappropriate medical decisions and potentially dangerous care gaps.
Impact on Interdisciplinary Care
The facility's Director of Nursing acknowledged the severity of these documentation failures, explaining that when nurses don't properly document assessments and symptoms, "it affected the residents' care" and "clinical documentation can greatly impact care because of the feedback in assessment and how that information is relayed to the physician."
Medical documentation serves as the primary communication tool between healthcare providers. When nurses fail to record complete assessments, including pain levels, physical findings, and symptom changes, physicians lack the information needed to make informed treatment decisions. This is particularly critical in nursing home settings where physicians may not be on-site continuously.
Medical Protocol Standards
Proper gastrointestinal assessment protocols require nurses to evaluate and document several key components when residents report constipation or abdominal pain. These include bowel sound assessment, abdominal inspection for distension, palpation for firmness or tenderness, and pain level documentation. The assessment should also include recent bowel movement history and associated symptoms like nausea or vomiting.
In this case, while nurses performed these assessments, the failure to document findings created dangerous gaps in the medical record. Standard nursing protocols require that all significant findings be recorded promptly and accurately to ensure continuity of care and appropriate medical interventions.
The resident's condition involved multiple concerning symptoms that developed over 48 hours, including two days without bowel movements, progressive abdominal pain reaching severe levels, breathing difficulties requiring increased oxygen support, and coffee-ground emesis suggesting possible gastrointestinal bleeding. Each of these symptoms requires specific medical attention and ongoing monitoring.
Facility Policy Violations
The facility's own policies clearly outline documentation requirements. Their Charting and Documentation policy states that "all services provided to the resident, progress towards the CP goals, or changes in the resident's medical, physical, functional pr psychosocial condition, shall be documented in the resident's medical record."
The policy emphasizes that documentation should be "objective, complete, and accurate" and include "assessment data and/or any unusual findings obtained during the procedure/treatment." The documented violations directly contradict these established standards.
Additional Issues Identified
Beyond the primary documentation failures, inspectors noted other concerning gaps including incomplete gastrointestinal evaluations during the evening shift and missing pain assessments in medication administration records. The resident's communication forms also lacked comprehensive symptom documentation despite nurses acknowledging they observed significant clinical findings.
The inspection classified these violations as having potential for minimal harm, though the cumulative effect of incomplete documentation during a medical crisis could have resulted in delayed or inappropriate treatment interventions. The facility's own nursing staff recognized that accurate documentation was essential for proper resident care and physician communication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inland Valley Care and Rehabilitation Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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