Inaccurate Medical Record Documentation After Resident Transfer
Penalty
Summary
Facility staff failed to maintain accurate documentation in the medical record of a resident who was admitted with chronic respiratory failure, anoxic brain injury, and metabolic encephalopathy. On the morning of the incident, the resident experienced tachycardia and low oxygen saturation, prompting a nurse practitioner to direct transfer to the hospital, which occurred around 9:00 AM. Despite the resident's transfer, the Medication and Treatment Administration Record for that night shift contained documentation indicating that vital signs were taken and medications and treatments were administered to the resident, who was no longer present in the facility. This discrepancy was confirmed through staff interviews and review of the medical record.