Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s change in condition and subsequent transfer to the hospital in the nursing progress notes. The resident was cognitively intact, was his/her own responsible party, and had multiple diagnoses including COPD, bipolar disorder, extrapyramidal and movement disorder, anxiety, insomnia, diabetes mellitus, malnutrition, and shortness of breath. The resident’s care plan, revised on 12/15/25, directed staff to monitor, document, and report signs and symptoms related to hypoglycemia, hyperglycemia, infection, and adverse reactions to psychotropic and antianxiety medications, as well as to record occurrences of target behavioral symptoms. The census showed the resident went on hospital leave on 12/27/25. Record review showed there was no nurse’s progress note documenting a change in condition, the need for hospital transfer, or physician notification on the date the resident was sent to the hospital. Interviews with the ADON, an RN, an LPN, and the Administrator confirmed that the facility’s expectation and practice were that the charge nurse document in the nurse’s progress notes the resident’s symptoms, concerns, vital signs, and notifications to the physician and responsible party whenever a resident is sent to the hospital. Despite these stated procedures, such documentation was absent for this resident’s hospital transfer.
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.