Failure to Timely Document Resident Transfer to ER
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to document the transfer of a resident to the emergency room (ER) following an episode of altered mental status and hypoxia. The resident, a female with a history of hip fracture, end stage renal disease, osteoporosis, and calciphylaxis, was transferred to the hospital but the event was not recorded in the clinical record at the time it occurred. The late entry documenting the transfer was created by the Director of Nursing (DON) over a week later. Additionally, the resident's family was not notified of the transfer at the time, and only learned of the hospitalization and subsequent diagnosis of urinary tract infection upon visiting the facility later that day. Interviews with the RN and DON confirmed that the proper procedure for timely documentation was not followed. The RN could not confirm that the family was notified, and acknowledged the failure to document the event as it happened. The facility's policy requires that all clinical events be documented in a comprehensive and timely manner, but this was not adhered to in this instance, resulting in incomplete and inaccurate clinical records for the resident.