Incomplete Documentation of Change in Condition
Penalty
Summary
The facility failed to ensure complete and accurate documentation for one resident, as required by federal regulations and the facility's own policy. Specifically, a review of the clinical record for one resident who experienced a change in condition and was transferred to the hospital did not contain official documentation of the change in condition. The facility's policy requires that all change in condition documentation include the date, time, assessment findings, actions taken, notifications, and resident response, and that this documentation be timely, accurate, and complete. During an interview, the Assistant Director of Nursing confirmed that the resident experienced a change in condition and was transferred to the hospital, but the required documentation was not present in the clinical record. It was suggested that the documentation may have been sent with the ambulance during the transfer, but it was not retained in the facility's records as required.