Failure to Document Vital Signs Prior to Hospital Transfer
Penalty
Summary
The facility failed to assess and document vital signs prior to non-emergent transfers to a general acute care hospital for two residents. For the first resident, who had chronic obstructive pulmonary disease and intact cognition, there was no documentation of vital signs being taken before her transfer to the hospital for increased difficulty breathing and lower leg edema. The last recorded vital signs were from the previous day, and the transfer was conducted without updated assessment. The Director of Nursing (DON) confirmed that it is expected for staff to obtain and document vital signs prior to any transfer, and that unstable vital signs would require ambulance transport rather than the facility van. Similarly, for a second resident with heart failure and moderate cognitive impairment, no vital signs were documented prior to her transfer to the hospital for shortness of breath, increased weakness, and lethargy. The last set of vital signs was recorded the day before the transfer. The DON reiterated that nursing staff are expected to obtain and document vital signs at least one hour before hospital transfer. Facility policy also requires nurses to make detailed observations and record relevant information in the medical record when there is a change in a resident's condition or status, including prior to transfer.