The Director of Nursing at Accura Healthcare of South Des Moines acknowledged to inspectors on September 17 that she had never documented her communications with an ENT clinic about a resident's nasal fracture. Three minutes after that admission, she created a "Late Entry Progress Note" in the resident's electronic health record with an effective date nearly a week earlier.
The resident, identified as having severe cognitive impairment with a mental status score of 4, had suffered the nasal fracture in a fall that sent them to the emergency department on August 27. Hospital discharge instructions specifically stated the resident should be re-evaluated by an ENT specialist within a week.
But no documentation of any ENT referral appeared in the resident's medical records.
The resident's diagnoses included Alzheimer's Disease, non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, and obsessive compulsive disorder. Medical records also documented hallucinations and delusions.
During her September 17 interview at 12:10 PM, the Director of Nursing told inspectors she thought she had first called the ENT clinic about the referral during the first week of September — more than a week after the hospital's recommended timeline. She explained to ENT staff that the resident had been seen in the emergency room for a nasal fracture and needed follow-up care.
The director also told the ENT clinic it would be difficult for the resident to be seen outside the facility due to their diagnoses and behaviors, requesting that the doctor review the resident's x-rays instead.
She said she called the ENT clinic again on September 10 after not hearing back, and was told the resident only needed to be seen if there were issues related to the fracture. If repair was wanted or needed, the resident would need to consult with plastic surgery.
None of this had been documented.
At 12:13 PM during the inspection interview — just three minutes after acknowledging the missing documentation — the Director of Nursing created the late entry progress note. She backdated it to September 10 at 11:30 AM, stating she had "received communication back from the ENT office. No follow up needed at this time, follow up if breathing issues develop. Resident's daughters were notified via email. In agreement with plan at this time."
The following day, September 18, both the facility administrator and Director of Nursing met with inspectors again. The Director of Nursing acknowledged her failure to document the communications with both the ENT clinic and the resident's family in the medical chart.
She verbalized the need for improvement in documenting these communications.
Federal regulations require nursing homes to maintain complete and accurate medical records for each resident in accordance with accepted professional standards. The violation affected one of three residents' records reviewed during the complaint inspection at the 82-bed facility.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
State inspectors noted that the facility's electronic health records contained no documentation of communication or referral to ENT specialists, despite the emergency department's clear discharge instructions for follow-up care within a week of the August 27 visit.
The resident's complex psychiatric and neurological conditions — including multiple forms of dementia and active hallucinations and delusions — made the lack of proper medical follow-up documentation particularly concerning for continuity of care.
The timing of the late entry creation, occurring during the inspection interview immediately after the director acknowledged the missing documentation, raised questions about the facility's standard practices for maintaining accurate medical records.
The facility must submit a plan of correction to continue participation in federal healthcare programs. The findings become public 14 days after the facility receives the inspection documents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of South Des Moines from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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