Park Place Nursing & Rehabilitation Center couldn't identify who used the initials "MP1" to sign off on daily wound treatments in their electronic medical records system. The facility's director of nursing pulled the complete staff list and found no employee assigned those initials.
The mystery deepened when LVN A admitted she had forgotten to document wound care she claimed to perform, then went back into the system the morning of the inspection to retroactively check off treatments. She told the director she "forgot to go to the WAR and check it off."
Resident #1 requires daily wound care for leg injuries. The treatments involve wrapping both legs with approximately nine pieces of xeroform dressing per leg. But documentation gaps left inspectors unable to verify whether the care actually occurred on multiple days.
LVN A said she normally documented wound care on the 24-hour report rather than the official Wound Assessment Record. She admitted floating between different units depending on staffing and working primarily from a different electronic system.
The director of nursing discovered the documentation problems when LVN A approached her asking for larger xeroform supplies. LVN A explained she was using about nine pieces per leg for Resident #1's treatments. The director then questioned how staff could prove the wound care was actually being performed.
When confronted during the inspection, LVN A said she had gone into Resident #1's chart that morning to document wound care she claimed to have performed on previous days. She told the director she had to backdate the entries because she forgot to check them off initially.
LVN B, another licensed vocational nurse, acknowledged similar documentation failures. She said she would "forget to sign out on the WAR when she completed wound care." She explained that morning shift typically handled wound care for residents in even-numbered rooms while evening shift treated those in odd-numbered rooms.
The resident told inspectors she was "treated good at the facility" and that staff performed wound care on her daily. She said her legs "had to be wrapped today" and expressed no concerns about her care.
But the documentation failures raised serious questions about care verification. LVN B acknowledged that accurate documentation was essential "to ensure it could be proved a resident was receiving their ordered care and so other nurses could determine what care had been provided."
The director of nursing emphasized the same point during her interview. She said she expected documentation to be completed daily as care was provided or medications administered. The importance, she explained, was "to prove care was provided and what was going on with the residents."
The facility's Electronic Medical Records policy, last revised in March 2014, states that "only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system." Yet someone gained access using initials that belonged to no authorized staff member.
The director told inspectors she was "never able to determine what staff member had been assigned initials MP1." She confirmed her own assigned initials in the system were "MP25," clearly different from the mysterious "MP1" entries.
The documentation gaps occurred despite the resident's complex medical needs. Diabetic patients require consistent wound monitoring and treatment to prevent serious complications. Missing or falsified records make it impossible to track healing progress or identify problems.
LVN A's admission that she retroactively documented care raised additional concerns about the accuracy of medical records. Healthcare regulations require contemporaneous documentation to ensure treatments are properly tracked and verified.
The facility had only one policy addressing medical records - their Electronic Medical Records policy. No additional protocols appeared to govern documentation accuracy or prevent unauthorized access to the system.
Multiple nurses acknowledged forgetting to document care they claimed to provide. This pattern of missed documentation combined with the mystery "MP1" entries suggested broader problems with record-keeping accuracy.
The case highlighted a fundamental problem in nursing home oversight: when documentation is missing or potentially falsified, there's no way to verify whether vulnerable residents received their prescribed care. For Resident #1, whose legs required daily wound treatments with multiple dressings, the documentation gaps left a troubling question unanswered about whether she actually received the care she needed.
Full Inspection Report
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