Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document in the clinical records of a resident who was sent to a General Acute Care Hospital from a dialysis center due to unresponsiveness. The resident, who was admitted to the facility with diagnoses including End Stage Renal Disease, anemia, and dysphagia, was picked up for dialysis in stable condition. However, the clinical records lacked documentation of the resident's transfer to the hospital, which was communicated to the facility by the resident's representative. During an interview and record review, a registered nurse acknowledged the omission, stating that she was busy and forgot to document the transfer. The facility's policy and procedure on nursing documentation requires that any communication with family, durable power of attorney, or physician should be noted in the nurse's notes. The failure to document the transfer had the potential to cause a delay in communication among staff and placed the resident at risk of not receiving appropriate care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Director of Nursing verified with Resident 76's hemodialysis center events that led to Resident 76 being transported to the General Acute Hospital and documented in Resident 76's clinical chart as a late entry. How do the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Medical Records Director conducted an audit of all discharges, including but not limited to discharges to the hospital, home, or discharges to another facility. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/26/25, the Director of Nursing in-serviced the Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN), on the policy and procedure titled, "Nursing Documentation," with emphasis on any communication with family, durable power of attorney, or physician, should be noted in the nurse's notes. The in-service also included ensuring documentation is inputted in the resident chart for discharges. The Medical Records Director will conduct an audit on discharge documentation daily for 5 days weekly for 2 weeks and monthly thereafter to ensure licensed nurses and registered nurses are documenting resident discharges in the resident's clinical progress note. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for clinical/nursing documentation related to discharges for three months or until compliance is met.