Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to follow professional standards of quality by not documenting assessments, interventions, or communications regarding a resident's change in condition and subsequent transfer to the hospital. The resident, who had a complex medical history including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and other serious conditions, experienced altered mental status and declining oxygen saturation. Although the nurse on duty assessed the resident, applied oxygen, and attempted to contact the provider before notifying the nurse manager and arranging for hospital transfer, none of these actions or the vital signs taken were recorded in the clinical record. Interviews with the DON, the nurse involved, and the regional nurse consultant confirmed that the expected standard was to document all assessments, changes in condition, and significant events such as hospital transfers at the time they occur. The nurse admitted to not documenting any of the events, including vital signs, communications, or the transfer itself, and did not consider making a late entry. Facility policy and professional nursing standards both require timely and complete documentation of such events, which was not followed in this instance.