Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility staff documented inaccurate data in a resident's medical record, as evidenced by a blood pressure reading recorded after the resident had already been discharged and transferred to the hospital. Specifically, a progress note indicated the resident was sent to the emergency room at the family's request, and another note confirmed the resident was out of the facility. Despite this, a blood pressure measurement was documented in the resident's chart after the discharge date. During an interview, the DON was unable to explain how or why this documentation occurred and confirmed that no vital signs should be recorded after a resident has been discharged.