The facility's Treatment Administration Record showed staff completed daily mediport flushes on Resident #9 from June 14 through July 7. The resident's mediport had been surgically removed on June 13.
A mediport is a small device surgically implanted under the skin to provide long-term access for medications, blood transfusions and blood draws. The device requires monthly flushing to prevent clots and maintain function.
Resident #9's physician had ordered the mediport flushed monthly starting May 4, with treatments due every month on the fourth day. Staff signed off the treatments as completed daily from May 4 through May 31, then June 4 through June 30, then July 1, and July 4 through July 7.
The resident underwent surgery to remove the mediport on June 13.
For the next 24 days, nursing staff continued signing the treatment records indicating they had flushed a device that no longer existed in the patient's body. Staff documented completing the procedure on June 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30. They signed off treatments on July 1, 4, 5, 6, and 7.
The facility's Director of Nursing confirmed during an October 10 interview that the order should only have been signed off on the date it was due — the fourth of each month — and only when actually completed.
"The order should not be signed off unless it was completed," the Director of Nursing told inspectors. He confirmed the mediport flush order should not have been signed off as completed on any dates after the device was removed.
The physician's order to flush the mediport was finally discontinued on July 8, nearly a month after the device's removal.
Federal inspectors discovered the false documentation during a complaint investigation at the 180-bed facility. They reviewed medical records for 12 residents and found inaccurate documentation affecting one patient.
The Treatment Administration Record serves as the official documentation of medical treatments provided to nursing home residents. These records are used by physicians, nurses, and other healthcare providers to track patient care and make treatment decisions.
Staff had also incorrectly documented the frequency of the mediport maintenance. The physician's order called for monthly flushing, but nursing staff signed off the treatment as completed daily rather than monthly from the order's start date in May.
The false documentation continued for weeks after the surgical removal, creating medical records that incorrectly indicated ongoing treatment of a device that was no longer present in the resident's body.
Medicare requires nursing homes to maintain medical records that are accurate and in accordance with accepted professional standards. The facility failed this requirement by allowing staff to document treatments that could not possibly have occurred.
The inspection report does not indicate whether the false documentation affected the resident's medical care or treatment decisions. It also does not specify what disciplinary action, if any, the facility took against staff who signed off on the impossible treatments.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The complaint investigation took place October 8-10, nearly three months after the false documentation period ended.
The facility has not publicly responded to the inspection findings. Montcare at Bethesda is required to submit a plan of correction to federal regulators detailing how it will prevent similar medical record violations in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Montcare At Bethesda from 2025-10-10 including all violations, facility responses, and corrective action plans.