Hawthorne Inn Of Danville

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records are complete and accurate for one of four residents (R1) reviewed for injuries in the sample list of eight.

Findings Include:R1's Nursing Notes document R1 admitted to the facility from the hospital on 7/10/25. R1's Nursing Notes, dated 7/10/25, do not document an assessment of R1's skin or if R1 had any skin issues or bruising. R1's Nursing Note, dated 7/13/25 at 3:39 PM, documents R1's incisions to left thigh, right groin, and chest are closed.

There is no documentation in R1's nursing notes between 7/10/25 and 7/16/25 that R1 had any bruising. R1's admission Observation, dated 7/10/25, documents there were no alterations in R1's skin. R1's Skin Assessment, dated 7/16/25, documents, Incisions & bruising. No new areas of concern.

This assessment does not document the location of R1's bruising. On 8/13/25 at 8:31 AM, V10, Registered Nurse, stated R1 admitted to the facility five weeks post Coronary Artery Bypass Grafting (CABG). V10 stated R1 had closed incisions to the groin, leg, and chest that were left open to air and no treatment needed. V10 stated R1 also had bruising to her hip or rib area. V10 stated nurses document weekly skin assessments and admission skin assessments under the observations section of the resident's electronic medical record, and this may also be noted in a nursing note. At 9:26 AM, V10 stated the bruising V10 documented in R1's skin assessment note 7/16/25 was the bruising V10 previously mentioned. V10 stated V10 did not consider the bruising to be a new issue since it was previously reported on R1's admission. V10 stated V10 had received report from the hospital the day R1 admitted and was told R1 had hip bruising. On 8/13/25 at 9:11 AM, V2, Director of Nursing, stated R1 admitted with bruising following CABG. V2 confirmed R1's admission assessments, skin assessments, and notes do not document R1 admitted with incisions or bruising. V2 stated V2 has requested R1's provider progress notes and is waiting on V29, Nurse Practitioner, to send R1's notes to the facility and obtain documentation that R1 had hip bruising on admission. R1's Progress Note, dated 7/11/25, recorded by V29 documents R1 was hospitalized on [DATE] and underwent left heart catheterization; R1 underwent two vessel CABG on 6/5/25 and developed a right femoral arterial sheath hematoma.

This note documents R1 had a midsternal incision that was dry and open to air, with no drainage or inflammation noted.

This note documents R1's left medial thigh incision from vein graft site was open to air, healed, and dry.

This note was included in R1's provider progress notes, provided by V2, with a facsimile cover sheet documents R1's notes were sent to the facility from V29 on 8/13/25 at 8:56 AM.

The facility's Job Description Medical Records, dated May 2013, documents responsibilities includes tracking and monitoring physician visits/notes, uploading documentation into the resident's electronic medical record, conducting audits of resident medical records and reporting discrepancies to the Director of Nursing.

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