Failure to Maintain Complete and Accurate Medical Records for Hospital Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was admitted with multiple diagnoses, including an infection of a left knee prosthesis. The resident, who was cognitively intact, reported being sent to the hospital via ambulance after a nurse left their PICC line uncapped overnight, resulting in the need for a new PICC line and a four-day hospital stay for antibiotics. Review of the resident's medical record revealed inconsistencies and missing documentation regarding the reason for the hospital transfer, the mode of transportation, and whether transfer paperwork was completed or sent with the resident. Nurse's notes contained conflicting information, suggesting both that the resident was transported by their partner and that they were transferred out to the hospital, but did not specify the reason for transfer. The facility administrator confirmed that the medical record lacked documentation explaining why the resident was sent to the hospital, how they were transported, and whether appropriate transfer paperwork was completed. The only available information about the reason for transfer was found in the hospital's emergency department report, which was not included in the resident's medical record at the facility.