Bridgepoint Rehab: Medical Records Violation - DC
The resident had a jejunostomy tube, which feeds directly into the small intestine through a surgical opening in the abdomen. But nursing staff consistently documented a gastrostomy tube in the resident's chart — a different device that feeds into the stomach.
The distinction matters. The two tubes require different care protocols and medication administration routes. A physician's history and physical examination from July 25 correctly identified the J-tube, noting "Gastrointestinal system soft, non-distended, J-Tube" and ordering continued tube feeding through the jejunostomy.
But nurses ignored the doctor's documentation. A July 29 nursing note stated "G-tube feeding is in progress." Two weeks later, another nurse wrote "On continuous G-tube feeding for nourishment. G-tube is intact, patent and infusing well."
The error continued into September. A nursing note from September 5 documented "Resident is G-tube dependent, G-tube intact and patent. No foul smelling discharge noted at the G-tube site."
Employee #3, an RN and unit manager, admitted the mistake during a September 19 interview with inspectors. "The staff documented g-tube in error," she said. "The resident had a J-tube and not a G-tube."
The facility's record-keeping problems extended beyond feeding tubes. Staff also misidentified the location of another resident's facial bruise, creating confusion about where the injury occurred.
A dementia patient developed skin discoloration that nurses initially documented correctly. An August 26 nursing assessment noted "skin discoloration on the right side on the top of her eye" and described "skin alteration noted on the top of the resident right eye. Appear yellow purplish measuring 1.1cm x 1.1cm."
But later that same day, a different nurse wrote that the injury was in a completely different location. The 5:18 PM nursing note stated "Small discoloration to right cheek remains the same no discomfort noted."
The facility's care plan, created the next day, added to the confusion by identifying yet another location. It instructed staff to "monitor the resident discoloration site on her right forehead."
Three different body parts — eye, cheek, and forehead — appeared in official records for the same bruise.
Employee #4, another RN and unit manager, acknowledged the error during a September interview. She told inspectors that "the nurses note dated 08/26/25 at 5:18 PM was an error. The resident had a bruise above her right eyebrow not her right cheek."
The inspection, conducted in response to complaints, found that two of seven sampled residents had inaccurate information in their medical records. Federal regulators cited the facility for failing to maintain records "in accordance with accepted professional standards."
Medical record accuracy is fundamental to patient safety. Nurses and doctors rely on charts to make treatment decisions, administer medications, and monitor patient conditions. When records contain wrong information about medical devices or injury locations, staff may provide inappropriate care.
The resident with the feeding tube received nutrition through Nepro formula infused at 40 milliliters per hour, with water flushes every four hours. Despite the documentation errors, nursing notes suggested the tube functioned properly and the resident's abdomen remained "soft to slight touch, non-distended."
For the dementia patient, nurses noted no signs of pain or discomfort from the facial bruising, regardless of where they thought it was located.
Both documentation errors persisted for weeks before managers acknowledged the mistakes to federal inspectors. The facility has not explained how nurses confused different types of feeding tubes or why multiple staff members documented different locations for the same facial injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harborside Health & Rehabilitation from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Harborside Health & Rehabilitation in WASHINGTON, DC was cited for violations during a health inspection on November 13, 2025.
The resident had a jejunostomy tube, which feeds directly into the small intestine through a surgical opening in the abdomen.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.