Federal inspectors found the documentation gaps at Concho Health & Rehabilitation Center during a December 19 complaint investigation. The missing records covered wound care supposedly provided on December 9, 13, 17, 19, and 22 for a resident admitted in November with heart failure, anemia, and type 2 diabetes.
The resident told inspectors during a December 18 interview that he receives his wound care as ordered by his physician and has never missed a treatment. "He stated he has never had an issue with his wound care and all of his wounds were healing," according to the inspection report.
But the facility's Treatment Administration Record showed blank entries for those five dates, creating what inspectors called a failure to maintain complete and accurate clinical records.
The Director of Nursing defended her staff during an interview the same day. She told inspectors "she knows all residents get their wound care" and explained that blank entries in the electronic system simply meant "an employee did not click that the care was completed." She insisted that "none of the residents in the facility have ever missed their wound care."
Two nurses offered similar explanations when pressed by inspectors about the missing documentation.
Licensed Vocational Nurse A acknowledged responsibility for the December 19 gap, which occurred during her shift. She told inspectors she "remembers directly that she did do the residents wound care" but "must have gotten super busy and just forgot to click that the treatment was completed."
The nurse admitted such lapses happen regularly. "She stated overall this can happen sometimes because it gets so busy in the facility."
Registered Nurse B also blamed distractions for incomplete documentation. She told inspectors she "made sure to do everyone's wound care" and insisted the gaps "does not mean the residents missed their care it means whoever provided the care did not click out of the system."
For the December 22 treatment specifically, she said "she knows she did it but might have gotten distracted to help another resident or by other staff and just didn't click completed."
The resident's care plan, dated December 18, identified him as having "a pressure ulcer or potential for pressure ulcer development." The plan called for his pressure ulcer to "show signs of healing and remain free from infection" while avoiding positioning him on the affected area.
His mental status assessment showed no cognitive impairment, with a score of 14 on the Brief Interview Mental Status exam.
The facility's own documentation policy requires maintaining "complete and accurate documentation for each resident on all appropriate clinical records sheets" and ensuring "information is comprehensive and timely and properly signed."
Federal inspectors determined the documentation failures put residents "at risk of not receiving needed services although services are documented as having been provided."
The inspection found that wound care documentation gaps represented a broader problem with the facility's electronic tracking system, where busy staff regularly fail to complete required entries despite claiming they provided the actual treatments.
The contradiction between what nurses said they did and what their records showed created uncertainty about whether the diabetic resident actually received his prescribed wound care on those five December days.
For a resident with pressure ulcers, diabetes, and heart failure, consistent wound care is critical to prevent infection and promote healing. Missing documentation makes it impossible to verify that such care occurred when needed.
The facility now faces federal oversight to correct its documentation practices, though the resident continues to report that his wounds are healing properly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concho Health & Rehabilitation Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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