Failure to Document Change in Condition and ER Transfer
Penalty
Summary
Facility staff failed to ensure that medical records were updated and accurate for a resident who experienced a significant change in condition. The resident, who had a history of surgical aftercare, peritoneal abscess, malignant carcinoid tumor, and a colostomy, was discharged to the emergency room due to a change in condition. However, the facility's electronic health record did not contain documentation of the change in condition, the reason for the transfer to the ER, or evidence that the facility's provider was notified of the transfer. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires documentation of any change in condition, notification of the provider, and the reason for sending a resident to the ER. Despite these expectations, there was no documentation in the resident's record regarding the change in condition, provider notification, or the rationale for the ER transfer, as confirmed by the DON.