Incomplete Medical Record Documentation for Resident Transfer
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted following joint replacement surgery and had multiple diagnoses, including dysphagia, aortic valve stenosis, hypertension, and recent gastrointestinal hemorrhage. The resident required significant assistance with activities of daily living, had an indwelling Foley catheter, and experienced frequent pain. On a specific date, the resident exhibited a change in condition, prompting the Nurse Practitioner to order diagnostic tests and treatments, and the resident was subsequently sent to the emergency room for evaluation and treatment. However, the nursing progress notes lacked documentation regarding the resident's condition at the time of transfer, the date and time the resident was sent to the emergency room, whether a report was called to the emergency room, any follow-up with the hospital, and there was no order documented to send the resident to the emergency room. The Assistant Director of Nursing confirmed that the medical record was incomplete and missing these critical details.