Failure to Assess and Document Resident Status Before and After Outside Appointment
Penalty
Summary
The facility failed to ensure that a licensed nurse completed and documented required assessments and vital signs before and after an outside medical appointment for one resident. The resident had been admitted with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, and was dependent on staff for ADLs and transfers. The resident’s history and physical indicated that the resident had the capacity to understand and make decisions. On the day in question, the resident left the facility with their spouse for an appointment with a pain specialist. Record review with the DON showed there was no nurse’s note, assessment, or vital signs documented in the medical record related to the resident’s departure for, or return from, the pain management appointment. In an interview, the LVN assigned to the resident that day confirmed that no assessment or vital signs were taken when the resident left for or returned from the appointment, despite acknowledging that facility policy requires assessments and vital signs in these circumstances. The DON also stated that the assigned licensed nurse should document vital signs and an assessment when a resident leaves and returns for a doctor’s appointment. The facility’s charting and documentation policy required that all services provided and any changes in the resident’s condition be documented to facilitate communication among the interdisciplinary team.
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