LOS ANGELES, CA - Federal investigators cited University Park Healthcare Center for systematic medical record violations after discovering seven residents had identical vital signs documented by the same licensed vocational nurse across multiple consecutive days.
Identical Vital Signs Documented for Multiple Patients
During a February 2025 inspection, Centers for Medicare & Medicaid Services surveyors identified a concerning pattern in medical documentation at the 230 E Adams Boulevard facility. Seven residents (numbered 77, 53, 341, 32, 62, 21, and 19 in the inspection report) had exactly the same vital signs recorded by Licensed Vocational Nurse 4 on February 8, 9, 10, and 11, 2025.
The identical documentation pattern represents a serious breach of medical record integrity. Vital signs including blood pressure, heart rate, respiratory rate, and temperature are critical indicators of patient health status that must be accurately measured and recorded for each individual resident.
When healthcare providers document identical vital signs for multiple patients, it typically indicates one of several problematic scenarios: the nurse failed to actually take the measurements, copied previous readings, or falsified the records entirely. Each of these possibilities compromises patient safety significantly.
Medical Significance of Accurate Vital Signs
Vital signs serve as the foundation of clinical assessment in healthcare settings. Blood pressure readings help detect cardiovascular complications, respiratory rate changes can signal breathing difficulties or infections, and temperature variations may indicate fever or hypothermia.
For nursing home residents, many of whom have multiple chronic conditions and take various medications, accurate vital signs are essential for detecting early warning signs of medical emergencies. A sudden spike in blood pressure could indicate a stroke risk, while changes in respiratory rate might signal pneumonia or heart failure.
When nurses document false or copied vital signs, clinical staff lose the ability to identify these critical changes. This creates substantial risk for missed diagnoses, delayed treatment, and potentially life-threatening complications going unnoticed.
Vulnerable Population Management Violations
The facility also faced citations for improper management of vulnerable residents who cannot make their own healthcare decisions. Investigators found 13 residents were being represented by the facility's Bioethics Committee, but the committee operated without established policies or proper guidance.
One resident, identified as Resident 19, was admitted with complex conditions including metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia. The resident had no known family and was unable to participate in care planning decisions.
The facility's Bioethics Committee consisted of the Medical Director, Administrator, Director of Nursing, and Social Worker. According to meeting minutes from November 2024, this committee determined the resident lacked decision-making capacity and voted to act as his responsible party for medical decisions.
However, investigators found the facility had no specific policies governing how the Bioethics Committee should operate or make decisions for vulnerable residents. The Administrator admitted during interviews that "there was no specific guidance followed by the committee."
Regulatory Standards for Medical Records
Federal regulations require nursing homes to maintain accurate, complete medical records that reflect each resident's actual condition and care provided. These records must be kept according to accepted professional standards and cannot contain falsified information.
The identical vital signs documentation violates these standards by creating inaccurate medical records that fail to reflect individual residents' actual health status. This type of systematic documentation failure indicates broader quality assurance problems within the facility.
Healthcare facilities are expected to have oversight systems that would detect and prevent such patterns of identical documentation. The fact that this occurred across multiple residents and multiple days suggests inadequate supervision and quality control processes.
Proper Bioethics Committee Protocols
When nursing home residents cannot make their own healthcare decisions and have no family or legal representatives, facilities may establish bioethics committees to provide guidance. However, these committees must operate under clear policies that ensure proper decision-making processes and resident protections.
Bioethics committees should include diverse perspectives, follow established ethical principles, and document their decision-making rationale thoroughly. They should also work actively to help residents obtain appropriate legal guardianship or conservatorship when needed.
The facility's Social Services Director indicated that applications for state conservatorship were submitted for residents under committee representation, but noted there was no specific timeline for this process. Four months elapsed between Resident 19's admission and assignment to a Deputy Public Guardian for investigation.
Industry Impact and Oversight
These violations highlight ongoing challenges in nursing home oversight and quality assurance. Medical record accuracy forms the foundation of quality healthcare delivery, and systematic documentation problems can indicate broader operational issues.
Federal inspectors noted that the deficient documentation practices created "increased risk for inadequate care of the residents." When clinical staff cannot rely on medical records to accurately reflect patient status, care quality inevitably compromises.
The facility received citations for minimal harm violations, meaning inspectors determined the problems had potential to cause harm but had not yet resulted in actual injury to residents. However, the systematic nature of the documentation issues suggests significant risk for future harm if not properly addressed.
Facility Response Requirements
University Park Healthcare Center must submit a plan of correction detailing how they will address these violations and prevent recurrence. The facility will need to implement stronger oversight of medical documentation practices and establish proper policies for bioethics committee operations.
Effective corrective measures typically include staff retraining, enhanced supervision protocols, and systematic auditing of medical records to ensure accuracy and completeness. The facility may also need to review all residents currently under bioethics committee representation to ensure proper legal protections.
Federal regulators will conduct follow-up inspections to verify that corrections have been implemented and sustained. Failure to adequately address these violations could result in more serious enforcement actions, including potential termination from Medicare and Medicaid programs.
The complete inspection report provides additional details about these violations and is available through the Centers for Medicare & Medicaid Services nursing home database for families and prospective residents reviewing the facility's compliance history.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Healthcare Center from 2025-02-13 including all violations, facility responses, and corrective action plans.
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