The falsified documentation at Clayton Rehabilitation and Healthcare Center came to light when federal inspectors investigated wound care practices in October. What they found was a pattern of nurses initialing treatment records for care that never happened.
Resident 26 had a Stage 3 pressure wound on his right ischium that required daily dressing changes with specialized antiseptic solution. The physician's order was specific: cleanse the wound with saline, pack it with gauze soaked in Dakin's solution, and cover with dry border gauze twice daily.
On October 19, the treatment record showed the wound was changed during both day and evening shifts. Nurse 3 had initialed the day shift entry. Nurse 1 had signed for the evening shift.
Neither nurse had touched the resident.
When inspectors called Nurse 3 on October 23, she said she hadn't changed the wound dressing "because his room was not on her assignment." The treatment nurse had done it instead, she claimed. Asked why her initials appeared on the record, she replied: "I do not know why my initials were on the TAR because I did not change the dressing."
Nurse 1 gave an identical story. She hadn't changed the wound either, she told inspectors during a phone interview that same day. The treatment nurse had done it. She couldn't explain her signature on the record.
But the treatment nurse, Nurse 13, revealed the scope of the deception when inspectors reached her. Resident 26's wound hadn't been changed since October 18, she said. When she finally changed the dressing on October 20, the old bandage she removed still bore her initials from two days earlier.
The wound had gone unchanged for at least 48 hours while two nurses documented care that never occurred.
A second resident suffered similar neglect. Resident 8 had undergone surgery in September to remove basal cell carcinoma from his back. The surgical site required daily cleaning with Dakin's solution and fresh hydrocellular foam dressing.
On October 10, the treatment record showed a blank space where documentation should have appeared. No dressing change had been recorded.
Nurse 20 later admitted to inspectors that she had performed the dressing change but failed to document it. The surgical site had been treated, but no record existed to prove it.
The administrator acknowledged the problem when confronted on October 27. Nursing staff should not be signing for care they didn't complete, she told inspectors.
The violations occurred despite clear physician orders for both residents. Resident 26's Stage 3 pressure wound required twice-daily attention with specific antiseptic protocols. Such wounds penetrate through the full thickness of skin and can lead to serious infection without proper care.
Resident 8's post-surgical site needed daily monitoring to prevent infection and ensure proper healing. Basal cell carcinoma removal requires careful wound management to avoid complications.
Federal inspectors documented the falsified records as a violation of medication and treatment administration requirements. The facility must ensure treatments are given as ordered and properly documented.
Treatment Administration Records serve as legal proof that residents received prescribed care. When nurses sign for treatments they didn't perform, it creates a false medical record that can mislead other caregivers about a resident's condition.
The investigation revealed a breakdown in both care delivery and documentation systems. Multiple nurses were willing to falsify records rather than ensure residents received prescribed treatments.
For Resident 26, the consequences were immediate. His Stage 3 pressure wound went without the specialized antiseptic treatment designed to prevent infection and promote healing. The wound remained packed with a dressing that was at least two days old when it should have been changed twice daily.
The facility's own treatment nurse discovered the deception only when she removed the old bandage bearing her signature from October 18. By then, the wound had been neglected through multiple shifts while nurses documented phantom care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clayton Rehabilitation and Healthcare Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Clayton Rehabilitation and Healthcare Center
- Browse all NC nursing home inspections