Failure to Obtain Complete Vital Signs Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice by not obtaining a complete set of vital signs prior to discharge, as required by facility policy. The resident, who had diagnoses including idiopathic peripheral autonomic neuropathy, unspecified epilepsy, and diabetes mellitus, was discharged home without a full set of current vital signs being documented on the day of discharge. Specifically, while the resident's blood pressure was recorded on the morning of discharge, other vital signs such as pulse rate, temperature, and respirations were last documented the previous evening. The Director of Nursing confirmed during interviews and record reviews that a complete set of vital signs should have been taken and documented immediately prior to the resident leaving the facility. Facility policy also required assessment and documentation of the resident's condition at discharge. The failure to obtain and document all vital signs before discharge was identified through review of the resident's medical record, progress notes, and discharge report.