Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain a complete and accurate medical record by not documenting a resident's change in condition that required Emergency Medical Services (EMS) intervention and subsequent hospitalization. The resident, who had chronic respiratory failure with hypoxia and end-stage COPD, was admitted to the facility on oxygen therapy. On the day of the incident, the resident was smoking a cigarette while receiving oxygen, resulting in a flash burn. The resident sustained burns to the upper left lip, singed nose hair, and a burn mark on the forehead, but did not report pain or breathing difficulties at the time. Despite the severity of the incident and the need for EMS transfer to a hospital, there was no documentation in the resident's electronic medical record regarding the change in condition or the events leading to the transfer. The nurse on duty confirmed that she did not document the incident, and the facility administrator verified that there were no nurse progress notes for the relevant shift. This lack of documentation constitutes a failure to maintain a complete and accurate medical record as required.