Failure to Document Resident's Emergency Room Visit and Return Assessment
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who was sent to the emergency room. The resident, an older adult with multiple diagnoses including diabetes, atrial fibrillation, COPD, and bipolar disorder, left the facility and was taken to the emergency room after being locked out and seeking help at a nearby restaurant. Upon her return, a head-to-toe assessment was performed by an LVN, but no documentation of the emergency room visit, the circumstances leading to it, or the assessment upon return was entered into the medical record. Interviews with facility staff revealed that the LVN did not document the assessment or complete an incident report because she was instructed not to by the Regional Compliance RN. The DON disagreed with this directive and believed documentation should have occurred. Other nursing staff, the administrator, nurse practitioners, and the medical director all stated that documentation of the emergency room visit and the resident's return assessment was expected and should have been completed. The Regional Compliance RN later stated that documentation was required and could not recall instructing staff otherwise. A review of facility policies indicated that accidents or incidents involving residents should be investigated and reported, and that nurses are required to complete descriptive documentation based on resident assessments. However, the facility did not have a specific policy addressing documentation requirements for residents returning from the hospital or emergency room. The lack of documentation in this case resulted in incomplete medical records for the resident involved.