Failure to Accurately Document Resident Death and Discharge Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical record for a resident who died after being transported to dialysis. Staff did not document in the progress notes that the resident was transported to dialysis and subsequently died at the dialysis center. Additionally, the facility's Admit/Discharge Report inaccurately listed the resident as discharged to home or self-care, rather than deceased. During interviews, the Assistant Director of Nursing confirmed the resident's death after dialysis, and the Administrator acknowledged the discharge status was not updated to reflect the resident's death. The Medical Director stated that staff are expected to document resident deaths in the clinical record and ensure records accurately reflect the resident's status.