Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had been transferred out of the facility. Specifically, vital signs were documented in the resident's medical record after the resident had already been discharged to the hospital. The resident, who had a history of pneumonia, asthma, and chronic obstructive pulmonary disease, was admitted in June 2025 and transferred to the hospital on June 28, 2025 at 7:32 p.m. However, the medical record showed that vital signs were recorded for this resident at 12:15 a.m. on June 29, 2025, after the resident was no longer present in the facility. During an interview and record review, the DON confirmed that the transfer form indicated the resident was no longer in the facility at the time the vital signs were documented. The DON acknowledged that this was an error in documentation. The facility's policy required that vital signs be obtained, recorded, and reported in a timely and accurate manner, which was not followed in this instance.