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Top Frequently Cited Standards: Documentation, Patient Care, and Safety Risks
This is the completion of the frequently cited clinical standards beginning with RC.02.01.01:
Record of Care – RC.02.01.01, EP 2
2026 Standard and EP: RC.12.01.01, EP 2
SPG Reference: SPG Page 151
During tracer activity, the medical record is a crucial part of the survey process because it enables the surveyor to compare practice with policy.
- Surveyors are looking for missing or incomplete documentation of protocols and orders such as ventilator weaning, oxygen titration, and blood transfusion.
- For example, a survey finding included a respiratory therapist who began the weaning process from the ventilator. An order for weaning the patient was not recorded; however, the respiratory therapist stated that they automatically wean based on a protocol. Upon reviewing the protocol, it was found to be over five years old, had not been approved, and the elements of the protocol were not included in the health record. In further discussion, the patient’s provider had not been notified that weaning had begun.
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Besides the issues with the order and protocol, the lack of protocol approval, the age of the protocol, and the absence of protocol contents in the patient health record were also cited as issues in the survey report.
- Inconsistent or absent clinical documentation, such as medications, vital signs, and allergy information.
- For example, surveyors will often evaluate admission orders or order changes, then determine whether the orders were carried out—for instance, medications administered, vital signs reassessed, or allergies documented in the case of vaccines.
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Non-compliance with policies, including missing assessments and treatment documentation. Where this issue becomes a survey finding is when the nursing assessment screen is reviewed by the surveyor and they see large areas where text boxes are blank. Finding the lack of documentation triggers questions regarding when assessments are done, the required content of the evaluation, and followed by the surveyor’s review of the assessment policy.
- The lack of content in the nursing assessment will likely result in a lower score in this standard. One additional note: when assessments suggest that “cutting and pasting” is occurring, then be prepared to discuss why assessment content is the same from shift-to-shift.
Leadership - Here’s what this means for hospitals preparing for the 2026
survey:
Conduct regular audits of protocol documentation and ensure linkage to standing orders in the EHR. The results of regular audits can be a very useful educational tool for nursing education. Using nursing documentation as a source of education for deposition preparation is also beneficial.
Behavioral Health – PC.01.03.01, EP 6
2026 Standard and EP: PC.11.03.01, EP 3
SPG Reference: SPG Pages 356–359
Plan of Care: Substance Diagnosis and Treatment Modalities
The following describes omission of active medical problems and interventions from treatment plans:
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In a recent survey report I reviewed, the surveyor examined the patient’s medical history just as closely as the psychiatric evaluation—and appropriately so. The patient had multiple significant medical conditions, including uncontrolled diabetes, renal disease, atrial fibrillation requiring medication and monitoring, and a history of falls. Although these issues were documented in the medical history and physical examination, none were reflected in the treatment plan.
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A fall risk assessment was completed on admission and each shift (as required by policy), but the treatment plan did not address the patient’s fall risk or related interventions. The surveyor ultimately cited this standard three times after reviewing three different treatment plans for patients with medical co-morbidities.
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Lack of documentation for alternative therapies when group sessions are refused. This finding occurs when a patient fails to attend group therapy, and an alternative plan for group therapy has not been conducted or documented. For example, suppose a specific topic for group therapy is part of the patient’s treatment plan, and the patient does not attend. In that case, the therapist is expected to develop an alternative strategy to deliver the information. That alternative plan must be documented in the patient's health record, the absence of the attending group must be noted in the treatment plan, and the method by which the absences are being addressed must be specified.
- Non-individualized or incomplete treatment modalities across patients:
- This finding is particularly common when a plan of care or treatment plan is created from a drop-down menu in the electronic record. The treatment plan must be individualized, each modality must be addressed in the treatment plan, along with interventions, goals, and evaluations of whether the treatment plan has been effective. Be watchful of drop-down menus and ensure all staff members individualize the plan based on the patient assessments, progress notes, and the admission history and physical.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
Standardize interdisciplinary review of treatment plans and include individualized interventions for each diagnosis. Additionally, evaluate treatment plan outcomes to determine if the chosen treatment modality was effective. Report back to the multidisciplinary treatment team the results of the audits, analyzed and trended.
National Patient Safety Goal – NPSG.15.01.01, EP 1
2026 Standard and EP: NPG.08.01.01, EP 1
SPG Reference: SPG Page 63
Suicide Safe Environment Risk Assessment
Unidentified or unmitigated ligature and self-harm risks and inadequate implementation or documentation of mitigation strategies:
- For example, during a survey on a behavioral health unit or in a behavioral health hospital, the surveyor will likely request the environmental ligature risk assessment. The surveyor will walk through the physical environment, then compare what was identified as a self-harm/ligature risk during that walk-through with the documented risk assessment. Behavioral health environments are challenging due to the daily and perhaps hourly patient activity (and creating dangers for self-harm). Surveyors are aware of and understand the unique aspects of behavioral health environments, and they will want to learn how the multidisciplinary team collaborates to address common physical environment impairments that the patient population may create.
- Presence of contraband or unsafe items accessible to patients:
- Finding contraband in the physical environment suggests that proactive assessments, staff education, and awareness may need to be enhanced. For example, finding rubber bands and paper clips in patient rooms, accessibility to cords and plastic bags in areas where patients at risk for suicide are left unattended, and bathrooms used by patients with ligature risks unmitigated by staffing.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
Ensure ligature and contraband risk assessments are routinely updated, documented, and verified by leadership rounds. Provide education as often as needed based on the level of risk as defined by the patient population. Ensure staff maintain a level of situational awareness regarding environmental risks, contraband risks, and family members who may be a source of contraband. Ensure that staff members follow hospital policies and procedures that address the handling of contraband.
Patient Care – PC.02.01.03, EP 7
2026 Standard and EP: PC.12.01.01, EP 1
SPG Reference: SPG Page 333
Patient Care Orders Followed:
This standard used to be a deemed standard, but now only the deemed component applies to “patient diets, including therapeutic diets ordered by a physician or other licensed practitioner… or by a qualified dietitian…” Other orders written for respiratory, radiology, rehabilitation, nuclear medicine, and dietary services that are not followed will be scored at this standard.
- Orders not followed or implemented as written, including ventilator and medication orders:
- For example, the surveyor will likely utilize a patient health record to track ventilator settings based on documented orders beginning in the Emergency Department through the admission process to the intensive care unit. Often, findings are identified when the patient is placed on a ventilator, and the respiratory therapist determines settings that are not supported by a written order. Suppose the respiratory therapist believes a respiratory rate of 24/min is more therapeutic than the rate specified in the provider's orders of 18/min. In that case, this observation will be documented as a finding at this standard.
- Incomplete documentation of care, such as vital signs, weights, and provider notifications:
- This finding is generally identified in the patient health record review (comparing orders with documented assessments). Additionally, if vital signs are required to be documented once per shift or every four hours, as defined by the unit's policies and procedures, then the surveyor will note the observation at this standard if gaps and blanks are found in the assessment record.
- Unauthorized changes to treatments without a provider order or documentation:
- An example of this finding is when telemetry is removed for transport to radiology without an order to discontinue telemetry. Other examples include changes to oxygen settings, removal of sequential compression devices without notifying the provider, changes in IV infusion rates, or deciding not to administer a blood transfusion without an order to discontinue. In these instances, it was likely that an order was received verbally, but the verbal order was not recorded by either the nurse or the ordering physician. Either way, without an order to change therapy or treatments, the observation is written at this standard and may be a high-risk finding.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
Reinforce accountability for order review and documentation compliance during shift handoffs and multidisciplinary rounds. Patient health record audits are very helpful in mitigating the risks of performing or changing care without a valid order. Analyze and determine if trends can be found, such as a specific shift, day of the week, short staffing, either nursing staff or medical staff, if one particular provider is identified who does not record the order, or if there is a perception by staff that changes can be made without an order. When I do chart reviews with nursing staff, at times, there is a question whether they can use “critical thinking” and change treatment based on their assessment. In most cases, the answer I give them is: “Get an order.”
Summary
The most frequently cited findings continue to emphasize incomplete documentation, inconsistent implementation of orders, and environmental safety risks. Strengthening interdisciplinary communication, standardizing documentation practices, and reinforcing policy compliance remain key strategies for reducing citations and improving patient safety.
If you have any questions regarding the content of this article or how to address noncompliance proactively, please do not hesitate to contact me by email at gnash@nashhc.com or by phone at 915-241-7830. My colleagues and I are very happy to help.
Have a great week and see you next Sunday
Gayle Nash, MPH, RN
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