Incomplete and Inaccurate Resident Transfer Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting the correct time on the Resident Transfer Record and by leaving several required sections incomplete. The resident, who had a history of Parkinson's disease, anxiety disorder, and spinal stenosis, was admitted with moderate cognitive impairment and required partial to moderate assistance with daily activities. On the day of the incident, the resident experienced lower abdominal pain, prompting a physician's order for hospital transfer. During the transfer process, the responsible RN documented two sets of vital signs: one at 10:45 a.m. on the SBAR form and another set, taken around 11:45 a.m., on the Resident Transfer Record. However, the RN mistakenly recorded the time as 10:45 a.m. on both documents, resulting in a discrepancy between the actual time the vital signs were taken and the time documented. Additionally, the Resident Transfer Record was found to have several blank sections, including the resident's Social Security Number, insurance information, date and time symptoms were first noted, current diet order, baseline mental status, and possessions transferred. Both the RN and the DON acknowledged the errors and omissions during interviews, confirming that the Resident Transfer Record was incomplete and contained inaccurate information regarding the timing of vital signs. The facility's policy requires that all health records be accurate, timely, specific, and complete, but these standards were not met in this instance.