Failure to Document Resident Hospital Transfer
Penalty
Summary
The facility failed to document the transfer of a resident to a general acute care hospital in the resident's medical records. The resident, who had chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube, was noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities. The physician had placed a telephone order for the transfer, but there was no documentation by facility staff regarding the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. During a review, the Clinical Manager confirmed that the medical records were incomplete and not accurate, specifically lacking documentation of the transfer event. Facility policies required complete and accurate documentation of all services provided and any changes in the resident's condition, but these were not followed in this instance. The absence of documentation was identified through interviews and record reviews, highlighting a failure to maintain systematic and accessible medical records as per facility policy.