Failure to Document Comprehensive Assessment Prior to Hospital Transfer
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to document a comprehensive nursing assessment for one of two sampled residents who experienced a significant change in condition. Specifically, the nursing progress notes for the resident, who was sent to the Emergency Department for coffee ground emesis (a sign of upper gastrointestinal bleeding), did not contain evidence that a comprehensive assessment was completed prior to transfer. During an interview and record review, the Director of Nursing confirmed that no assessment was documented, despite the expectation that one should have been completed. This lack of documentation was identified through review of nursing progress notes covering the period before the resident's transfer.