Failure to Document Resident Condition and Events During Emergency Discharge
Penalty
Summary
The deficiency involves the facility’s failure to document the condition and circumstances surrounding the emergency discharge of one resident. The resident was admitted on 1/21/26 and discharged on 6/25/25, and the clinical record contained a single progress note dated 6/25/26 stating that the resident was very aggressive toward a CNA during care and injured the CNA’s wrist. The note further indicated that the DON witnessed the incident, called the police, and that the resident was sent out around 10:30 a.m. on a gurney via emergency transportation. No additional progress notes were documented regarding this event, and the resident’s record did not contain further details of the emergency discharge or the events leading to the transfer. During interview and concurrent record review, the LVN who wrote the progress note stated she was assigned to the resident that day but did not clearly remember the incident because the DON handled the situation while she was passing medications. The LVN reported she was a brand-new nurse and did not know she was supposed to complete an SBAR for the event. The Administrator confirmed that the DON referenced in the note was no longer employed at the facility and that the LVN had started but not completed an SBAR. The Administrator stated there should have been notes about the resident’s transfer and acknowledged that both the progress note and SBAR were incomplete. Review of the facility’s Transfer and Discharge policy showed that for emergency transfers/discharges initiated by the facility, nursing staff are required to document assessment findings and other relevant information regarding the transfer in the medical record, which was not done in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.