Failure to Accurately Assess and Document Resident Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and accurately document the condition of a resident who was transferred to the emergency room for a rash on the leg, later diagnosed as cellulitis. The facility's policy requires comprehensive assessment and documentation during incidents and significant status changes, including reviewing previous notes, documenting findings, and notifying relevant parties. However, the Change in Condition Evaluation form completed by an LPN on the day of the second transfer lacked updated vital signs, relevant observations, and a summary of the nurse's evaluation and recommendations. The vital signs and notification times recorded were from the previous day, and the most recent blood glucose value was several months old. Additionally, the form did not indicate whether the condition had occurred before, incorrectly marking it as "Unknown" despite the same issue prompting a hospital visit the previous day. There was also no documentation of updated notifications to the primary care clinician or the resident's healthcare power of attorney regarding the second transfer. These omissions were confirmed by the Assistant Director of Nursing, who acknowledged the lack of accurate and current assessment and notification documentation for the resident's second emergency room transfer.