Inaccurate Clinical Record of Resident Hospital Transfer
Penalty
Summary
Facility staff failed to maintain an accurate clinical record for one resident by incorrectly documenting a transfer to the emergency room. Progress notes included late entries stating that the resident experienced shortness of breath, received a full assessment, and was transferred to the ER by EMTs. However, subsequent documentation in the clinical record did not show evidence that the resident actually went to the ER on the date in question. Additionally, a respiratory evaluation note from later that morning indicated the resident was stable, with no shortness of breath or need for suction, and remained on room air. Interviews with nursing staff revealed discrepancies in the documentation. The RN who regularly cared for the resident stated that the resident was never sent to the hospital on the date documented and that the nurse who wrote the change in condition note did not work on the unit at that time. The LPN who authored the late entry notes admitted to mistakenly entering the wrong date for the hospital transfer, as she had documented the event after the fact and was unsure how to correct the error. The facility's policy requires that recorded entries be complete and contain essential information, which was not met in this instance.