Licensed Practical Nurse #233 told federal inspectors at Avon Place Healthcare Center that she "probably just marked on the TAR that the securement device was in place even though LPN #233 knew it was not." The nurse verified she falsified the medical record by clicking in the electronic system that she had monitored equipment that didn't exist.
The falsified records involved a paralyzed diabetic patient with multiple serious conditions including stage four chronic kidney disease, morbid obesity, and delusional disorders. Resident #15 had a suprapubic catheter that required a securement device to prevent dangerous dislodgement.
The facility's care plan, revised in September, specifically required the securement device to prevent catheter problems. Physician orders from October 16 directed staff to monitor the catheter stabilization device daily and every shift.
Yet when inspectors observed Resident #15 on October 22, the catheter had no securement device. The resident and her husband told investigators neither believed she had ever had a catheter securement device while at the facility.
The nurse's confession revealed systematic falsification. LPN #233 worked third shift with Resident #15 on October 16 and 17 and told inspectors she didn't recall the resident having a catheter securement device present either night. She said she knew the device wasn't there "because when they roll Resident #15 to the side, they always place the catheter on the bed."
Despite knowing the required safety equipment was missing, the nurse continued documenting its presence in the electronic medical record system.
A certified nursing assistant confirmed the catheter lacked the required securement device during the inspection.
The Treatment Administration Record for October showed nurses documented every shift that the foley securement device was in place. These entries were false.
Catheter securement devices prevent potentially serious complications from accidental dislodgement, particularly critical for residents with complex medical conditions like Resident #15. The resident's paraplegia, combined with diabetes and advanced kidney disease, made proper catheter management essential for preventing infections and other complications.
The facility's own policy on charting and documentation, last revised in July 2017, required that all medical record documentation be "objective, complete, and accurate."
Federal inspectors found the violation during a complaint investigation numbered 2643404. The inspection occurred after someone filed a complaint about conditions at the 73-bed facility.
The falsification affected one of three residents whose medical records inspectors reviewed for accuracy. But the systematic nature of the false documentation, with entries made across multiple shifts over weeks, suggested the problem extended beyond a single oversight.
LPN #233's admission that she "probably just marked" false information while knowing the truth revealed a casual attitude toward medical record integrity. Her statement that she knew the device was missing because of how staff handled the catheter during routine care indicated the absence was obvious to anyone providing direct patient care.
The resident's husband's presence during the inspection interview, and his confirmation that his wife never had the required safety device, underscored how the falsification potentially put the patient at ongoing risk while creating a false paper trail of compliance.
Resident #15's complex medical profile made accurate documentation particularly crucial. Her combination of paraplegia, diabetes with neuropathy, morbid obesity, and stage four kidney disease created multiple risk factors that proper catheter management was designed to address.
The October physician orders specifically calling for daily monitoring of the stabilization device showed medical staff recognized the importance of the equipment. Yet the nursing staff's systematic false documentation meant doctors and administrators had no accurate information about whether their orders were being followed.
The violation occurred despite the resident having intact cognition, meaning she was mentally capable of understanding her care and communicating about problems. Her and her husband's clear statements that the device was never present contradicted months of nursing documentation claiming otherwise.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But the deliberate falsification of medical records represented a fundamental breach of professional standards and patient safety protocols.
The nurse's matter-of-fact admission suggested the falsification wasn't an isolated incident but part of routine practice when required equipment was missing or monitoring wasn't actually performed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avon Place Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.