The June 25, 2025 incident at Cornerstone Care Center left Resident 2's medical record incomplete, with no details about why he was discharged or the events that led to the emergency removal, according to a January 29 state inspection.
The only record of the incident was a brief progress note stating: "Resident was very aggressive to CNA during care and hurt CNA wrist. DON witness and called police. Resident was sent out approx. 1030 am on gurney via emergency transportation."
Nothing else was documented about the emergency discharge.
Licensed Vocational Nurse 1, who wrote the progress note, told inspectors she was assigned to Resident 2's care that day but didn't handle the situation directly. "That day, I don't really remember, my DON came in and dealt with the situation because I was passing medications," she said during the January interview.
The nurse, who described herself as "brand new," admitted she didn't know she was supposed to complete an SBAR report for the incident. SBAR is a standardized communication tool that requires nurses to document the situation, background, assessment and recommendations for patient transfers or emergencies.
"I didn't know I was supposed to make a 'SBAR' for that," LVN 1 told inspectors.
The facility administrator confirmed that the Director of Nursing referenced in the progress note was no longer employed at the facility. During the inspection, the administrator acknowledged multiple documentation failures surrounding Resident 2's emergency departure.
"LVN 1 had started a 'SBAR', but it was incomplete," the administrator told inspectors. "There should be notes about [Resident 2's] transfer. The Progress Note was incomplete, the 'SBAR' was incomplete, and [LVN 1] clearly did not complete this."
The incomplete documentation violated the facility's own transfer and discharge policy, which specifically requires staff to "document assessment findings and other relevant information regarding the transfer in the medical record" for emergency discharges.
According to the facility's policy dated December 19, 2022, emergency transfers are "initiated by the facility for medical reasons to an acute care setting, such as a hospital, for the immediate safety and welfare of a resident."
The policy places documentation responsibilities on nursing staff "unless otherwise specified."
Resident 2's admission record showed he was admitted to Cornerstone Care Center on an unspecified date and discharged on June 25, 2025. The inspection report noted that the progress note about the incident was dated June 25, 2026 — appearing to be a clerical error, as the discharge date was listed as June 25, 2025.
The documentation failure meant that critical information about Resident 2's condition, the circumstances of his emergency removal, and the assessment that led to calling both an ambulance and police was never properly recorded in his medical record.
Federal regulations require nursing homes to maintain comprehensive clinical records for all residents, including detailed documentation of any emergency situations that result in transfer or discharge.
The inspection found that the facility failed to provide required documentation related to the resident's needs during the discharge process. State inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The case highlights the importance of proper documentation during emergency situations, particularly when incidents involve resident aggression, staff injury, and law enforcement response. Without complete records, facilities cannot demonstrate they followed appropriate protocols or provided adequate care during critical moments.
Resident 2's medical record remains incomplete, with no follow-up documentation about his condition or the events that led to his emergency removal from the facility on that June morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cornerstone Care Center from 2026-01-29 including all violations, facility responses, and corrective action plans.