Federal inspectors found Mission Valley Nursing and Transitional Care failed to promptly update Resident #3's care plan after he signed DNR paperwork. The resident suffered an unwitnessed fall during the gap period when his records contradicted each other.
The facility's Director of Nursing acknowledged the dangerous mix-up during an October interview with inspectors. She confirmed Resident #3's care plan showed "Full Code" status on the same date he signed his DNR order, but staff didn't update the plan until five days later.
"It would not have been clear if the resident was DNR if anything had happened to the resident" during those five days, the director told inspectors.
Something did happen. Resident #3 fell without witnesses during the period when his records conflicted. Though he sustained no obvious injuries, the incident highlighted how the delayed paperwork could have created life-or-death confusion for emergency responders.
The nursing home's own policy required immediate care plan updates when residents experienced status changes. The facility's Care Plan Revisions Upon Status Change policy, dated earlier this year, explicitly stated that care plans "will be updated with the new or modified interventions" and required designated staff to "conduct an audit on all residents experiencing a change in status, at the time the change in status is identified."
Staff interviews revealed a system where multiple nurses handled different pieces of the DNR process, but nobody ensured timely completion. RN X told inspectors that admitting nurses added initial code status information and updated care plans when status changed. She said nurses who received DNR orders were responsible for discontinuing full code status and documenting the change.
The facility required nurses to wait for signed psychotropic medication consent before entering drug orders into the computer system, preventing medications from appearing on administration records until families approved treatment. But no similar safeguards existed for DNR documentation.
LVN GG described how social workers notified nurses of code status changes, who then updated records and documented the switch to DNR in comment sections. She said admitting nurses completed initial care plans while registered nurses reviewed and signed off on them.
The inspection found the facility's medication consent process more rigorous than its life-and-death decision tracking. Staff told inspectors that psychotropic medications couldn't be entered into computer systems until families signed consent forms, ensuring drugs wouldn't appear on medication administration records until properly authorized.
No such verification system existed for DNR orders.
The five-day delay between signing and implementation meant Resident #3's wishes remained unclear in his official care documentation. Emergency medical personnel responding to his fall would have seen conflicting information about whether to attempt resuscitation.
Federal inspectors cited the facility for failing to ensure care plans reflected residents' current needs and preferences. The violation fell under regulations requiring nursing homes to develop comprehensive care plans that address each resident's medical, nursing, and psychosocial needs.
The facility's policy required unit managers or designated staff to audit all residents experiencing status changes "at the time the change in status is identified" to ensure care plans reflected current needs. The five-day gap violated this requirement.
Mission Valley Nursing's documentation failures created exactly the scenario the Director of Nursing described to inspectors. Staff responding to Resident #3's fall faced contradictory records about his end-of-life preferences during a moment when such clarity could determine whether he lived or died according to his own wishes.
The inspection found the facility failed to implement its own written procedures for timely care plan updates following resident status changes. While staff understood their individual roles in the DNR process, the system lacked accountability measures to ensure completion within required timeframes.
Resident #3's experience illustrated how administrative delays can override patient autonomy in nursing homes, where residents' most fundamental healthcare decisions may sit in bureaucratic limbo during medical emergencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Valley Nursing and Transitional Care from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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