Failure to Document Psychiatric Incident and Hospital Transfer in EHR
Penalty
Summary
The facility failed to include critical documentation in the electronic health record (EHR) for a resident who experienced a significant behavioral incident that resulted in a psychiatric petition and transfer to a hospital. The resident, who had diagnoses including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance, became increasingly agitated and aggressive, culminating in physical altercations with staff and other residents. Despite staff interventions, including administration of PRN medications and attempts at redirection, the resident's behavior escalated to the point of property damage and threats of violence. An incident report was created by the DON detailing the resident's actions, staff responses, and the subsequent decision to transfer the resident to a hospital under a psychiatric petition. This report included information about the administration of Haloperidol and the use of emergency services. However, this incident report was marked as "Privileged and Confidential - Not part of the Medical Record," and the corresponding clinical documentation was not entered into the resident's EHR. Upon review, the DON acknowledged that the incident and the rationale for the psychiatric petition should have been documented in the resident's clinical record, as it reflected significant changes in the resident's condition and the facility's inability to provide appropriate care at that time. The facility's own policy required documentation of all services, changes in condition, and incidents in the medical record, but this was not followed in this case. No additional documentation was provided by facility leadership when requested.