Failure to Document Nurse-to-Nurse Reports at Discharge
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate for two residents who were discharged to other facilities. For both residents, physician orders required that a nurse-to-nurse report be given to the receiving facility at the time of discharge. However, there was no documentation in either resident's medical record indicating that this report was provided, despite staff interviews confirming that the reports were given verbally. The absence of this documentation resulted in incomplete and inaccurate medical records for both residents. One resident, admitted with diagnoses including cerebral infarction, diabetes mellitus, and generalized muscle weakness, was discharged to another facility with a physician order specifying a nurse-to-nurse report. Another resident, with spinal stenosis, diabetes mellitus, and a history of falls, was also discharged under similar orders. In both cases, staff acknowledged during interviews that the nurse-to-nurse reports were not documented in the residents' records. Facility policy required that all services provided, including communication with other staff or facilities, be documented in the medical record to ensure completeness and accuracy.