Failure to Document Critical Assessment Data Prior to Hospital Transfer
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a complete and accurate clinical record for a resident with Alzheimer's disease, type 2 diabetes mellitus, and myotonic muscular dystrophy who experienced a significant change in condition. The resident was found barely responsive, with labored breathing, tachycardia, pale and cold skin, and appeared very weak. Despite these symptoms and the resident's known diabetes diagnosis, neither a body temperature nor a blood glucose level was documented or communicated to the provider prior to the resident's transfer to the emergency department. The facility's own policy required prompt and complete documentation of assessments and significant events, but this was not followed. Upon review, it was found that the hospital documented the resident as febrile and with a critically high blood glucose level upon arrival. Interviews with nursing staff revealed that although a nurse performed an assessment and believed she had obtained vital signs and a blood sugar, she did not document these findings before the end of her shift, citing the resident's condition as a distraction. The Director of Nursing confirmed that documentation should have been completed as close to the event as possible, and was unaware that it had not been done. The lack of documentation resulted in an incomplete clinical record regarding the care provided prior to the resident's transfer.