Incomplete Documentation of Assessments and Transfer for Resident with COVID-19
Penalty
Summary
The facility failed to document complete and accurate assessments for one resident who had multiple diagnoses, including repeated falls, malignant neoplasm of the prostate, COVID-19, and chronic atrial fibrillation. After being admitted from the hospital emergency room following a fall, the resident's nursing assessments on the first two days did not indicate any respiratory symptoms and documented the resident as negative for respiratory signs. However, there were no head-to-toe or respiratory assessments documented for the following three days, despite the resident testing positive for COVID-19 and exhibiting symptoms such as chest congestion and cough. Progress notes indicated that COVID-19 isolation precautions were initiated and that the resident's power of attorney was notified. However, there was no documentation regarding subsequent assessments, the resident's transfer to the hospital, the rationale for the transfer, or whether the physician or family were informed of the transfer. The Director of Nursing acknowledged the lack of documentation and stated that it was expected for respiratory assessments and transfer documentation to be completed when a resident becomes symptomatic and is sent to the hospital. The facility's policy also requires physician notification in the event of a transfer or discharge.