Avenir at Mark Twain's staff scheduled appointments but never recorded what happened during the visits, missing infectious disease consultations, cardiology follow-ups, and pain management sessions between May and August 2025.
Resident #9 has atrial fibrillation, stroke complications, a pacemaker, heart failure, and an infection of cardiac devices. The facility scheduled seven appointments from May through August: eye doctor, cardiology, infectious disease, foot surgery consultations, and a wellness visit.
None were documented properly.
On May 30, a nurse received a call that the resident arrived late to an infectious disease appointment. The appointment was rescheduled for August 4. No record exists of what happened at the rescheduled visit.
The resident attended a cardiology appointment on May 27 for heart failure and atrial fibrillation monitoring. No documentation. Same pattern for eye care on May 20, foot surgery consultations on July 15 and August 19, and a wellness visit on August 14.
Resident #68 faces similar documentation gaps. This resident has stroke, high blood pressure, swelling, breast cancer, an enlarged heart, atrial fibrillation, and lower back nerve pain requiring specialist care.
Five appointments went undocumented: primary care on May 15, eye doctor on May 20, pain management on June 13 and July 10, and neurology on June 17.
During an August 19 interview, the resident said appointments are sometimes missed due to transportation delays. "I have many doctor appointments due to my many medical conditions," the resident told inspectors.
The documentation failures mean the facility has no record of new medication orders, treatment changes, or follow-up appointment schedules from any of these visits.
LPN J explained the expected process during an August 19 interview. When residents leave for appointments, staff should document their departure and destination. Upon return, notes should include the resident's condition, information about the appointment, any new orders, and scheduling for future visits.
"All that information should be documented in the progress notes," LPN J said.
The Administrator and Director of Nursing confirmed this policy during an August 20 interview. Progress notes are required every time residents leave for appointments and when they return, including departure times, destinations, return times, new recommendations, orders, and future appointments.
If residents miss appointments, that also requires documentation.
The Director of Nursing was unaware of other documentation problems. She told inspectors that charge nurses oversee resident weights, while resident assistants obtain weights and enter them into electronic medical records. All weights should be entered "timely and accurately to avoid any inaccuracy."
She didn't know that resident assistants weren't entering weights directly into the system.
The missing documentation affects residents with complex medical needs requiring coordination between multiple specialists. Resident #9's infected pacemaker requires infectious disease monitoring. The cardiology appointments monitor heart failure and irregular heartbeat. Without documentation, staff cannot track treatment progress or medication adjustments.
Resident #68's pain management appointments address nerve compression in the lower back. The neurology visits monitor stroke recovery and brain function. Missing documentation means staff lack information about pain medication changes or neurological status updates.
The facility's transportation delays compound the documentation problems. When residents arrive late or miss appointments entirely, the lack of documentation means no tracking of rescheduled visits or missed care opportunities.
Federal regulations require nursing homes to maintain accurate medical records documenting all aspects of resident care, including specialist consultations and treatment changes. The missing appointment documentation violates these requirements and potentially compromises resident safety.
Both residents continue living at the facility with ongoing medical needs requiring specialist coordination. Without proper documentation systems, staff cannot ensure continuity of care or track treatment effectiveness for residents managing multiple chronic conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenir At Mark Twain from 2025-08-20 including all violations, facility responses, and corrective action plans.