Failure to Document Resident Transfer to Hospital
Penalty
Summary
A deficiency occurred when the facility failed to document the transfer of a resident to a general acute care hospital (GACH) in the resident's medical records. The review of the resident's records showed that there was no documentation by facility staff indicating the transfer, despite a physician's telephone order for the transfer being present. The Clinical Manager confirmed during an interview and record review that the medical records were incomplete and not accurate, specifically noting the absence of documentation regarding the resident's transfer. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube placement. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities such as oral hygiene, toileting, and dressing. The resident did not have the capacity to understand or make decisions, as indicated in the history and physical and the Minimum Data Set (MDS) assessment. Facility policy and procedure documents reviewed indicated that all services provided, progress toward care plan goals, and any changes in the resident's condition should be documented in the medical record. However, in this instance, the licensed nurse did not document the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. This lack of documentation resulted in incomplete medical records for the resident.
Plan Of Correction
F-628 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. On 9/9/25, the Director of Nursing (DON) gave the transferring RN for Resident 1 an inservice about the facility's policy on discharge process. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. Identification of Others On 9/11/25, the DON and Clinical Manager assessed other discharge charts. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.