Incomplete Documentation of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident who was transferred to the hospital following a change in condition. The resident, who had multiple complex diagnoses including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and other serious conditions, was assessed as cognitively intact. On the date of the incident, the clinical record lacked documentation regarding the resident's change in condition, assessments performed, interventions implemented, and communications that led to the hospital transfer. The only nursing note present was entered after the transfer, stating the resident had been sent to the emergency department on the prior shift. Interviews with the DON and the nurse who cared for the resident during the incident confirmed that no documentation was made regarding the vital signs, attempted provider communication, or the decision to transfer the resident. The nurse stated he assessed the resident multiple times, noted declining oxygen saturation and blood pressure, and communicated with the on-call nurse manager, who instructed him to send the resident to the hospital. However, none of these actions were documented in the clinical record, and the nurse did not consider making a late entry. Facility policy required documentation of assessments and provider notifications for significant changes in condition, which was not followed in this case.