Failure to Document Change of Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to ensure that a change of condition was properly documented and communicated for two residents who were transferred to a general acute care hospital (GACH). For one resident with diagnoses including cognitive communication deficit, type 2 diabetes mellitus, and generalized muscle weakness, there was no eInteract Change of Condition/SBAR form completed by the licensed nurse at the time of transfer for a urinary tract infection. The Minimum Data Set Coordinator confirmed that the required documentation, which should detail the events leading to the transfer and the interventions provided, was missing. The Director of Nursing also stated that the SBAR/Change of Condition form is essential for communicating the resident's status and the care provided during such incidents. Another resident, with a history of acute osteomyelitis, neuropathic bladder, and paraplegia, was transferred to the hospital on two occasions. On one occasion, the progress notes only indicated the transfer for critical laboratory results without documenting vital signs, primary diagnosis, code status, nursing observations, or notifications to the primary physician and resident representative. On another occasion, although an SBAR/Change of Condition was created for worsening edema, it was not updated to reflect the actual transfer, and the provider notified was not documented. The Director of Staff Development and Assistant Director of Nursing both acknowledged that the required documentation was incomplete or missing, which is necessary to ensure safe transfer and accurate communication of the resident's condition and care. The facility's policy requires that any change in a resident's condition be documented in detail, including the incident, assessments, notifications, and updates to the care plan. However, in both cases, the facility did not follow its own procedures, resulting in incomplete records of the residents' changes in condition and the care provided prior to hospital transfer. This lack of documentation could lead to delays in care and inadequate communication among healthcare providers and resident representatives, as noted in the findings.