Failure to Document Hospital Transfer and Return in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who experienced an acute hospital transfer and subsequent return. On the date in question, there was no nursing documentation regarding the resident's change in condition, the assessment prior to transfer, physician notification, or details of the hospital transfer and return. The facility's policy requires supporting documentation for all diagnoses and changes in a resident's status, including evaluations, indications of distress, and changes in functional status, but this was not followed in this instance. The resident involved had multiple diagnoses, including Parkinson's Disease, Atrial Fibrillation, Asthma, Depression, Anxiety Disorder, Paranoid Disorder, muscle weakness, difficulty walking, and lack of coordination, and was cognitively intact. The resident reported experiencing numbness and weakness in one arm, which led to calling EMS and being transferred to the hospital. The nurse on duty was unaware of the transfer until after it occurred and did not assess the resident, communicate with EMS, or document the event in the medical record. The DON confirmed that documentation of the transfer and return was expected but not completed.