Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who experienced a significant change of condition (COC) that resulted in transfer to a general acute care hospital. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was observed by staff to be crying, complaining of chest pain, and had an oxygen saturation of 82%. Paramedics were called, and the resident was subsequently transferred to the hospital, where she was diagnosed with bilateral extensive pulmonary embolism and admitted for treatment. Despite these events, there was no documented evidence in the resident's medical record of the COC, progress notes, or physician orders for the transfer to the hospital. Interviews with nursing staff and a review of facility policies confirmed that documentation of such events is required, including completion of a COC form, progress notes, and notification of the physician and family. The lack of documentation meant that the resident's condition and the care provided were not accurately reflected in the medical record. Facility policies reviewed indicated that all changes in a resident's condition, services provided, and significant events must be documented to facilitate communication among the interdisciplinary team and ensure continuity of care. The failure to document the resident's COC and related interventions was not in accordance with accepted professional standards and the facility's own policies and procedures.