Failure to Document Resident's Return from Hospital
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who returned from the hospital. Specifically, there was no documentation by the assigned LVN regarding the resident's return, including the time of return, new orders, or vital signs. The expectation was for staff to document these elements upon a resident's return from the hospital, but this was not completed. The LVN responsible acknowledged that the readmission assessment was not performed, citing a busy shift and communication issues as contributing factors. The resident involved was an older male with multiple complex medical diagnoses, including cerebrovascular disease, seizures, psychotic disorder, substance dependence in remission, generalized anxiety disorder, major depressive disorder, lack of coordination, muscle weakness, rhabdomyolysis, mild cognitive impairment, and a history of stroke. He had recently experienced a fall in the facility, resulting in a laceration and hematoma to his left forehead, and was sent to the hospital for evaluation. Upon his return, there was no documentation in the medical record to reflect his condition, any new orders, or interventions performed at the hospital. Interviews with facility staff confirmed that documentation was not completed as required. The ADCO and DCO both stated that staff are expected to document upon a resident's return from the hospital, including any new orders and interventions, and that failure to do so could impact continuity of care. The facility did not have a specific policy on accuracy of documentation, but training was provided to staff on documentation expectations. The lack of documentation was identified during the survey process and acknowledged by facility leadership.