Failure to Assess Change in Condition and Accurately Document Vitals Before Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident experiencing a change in condition prior to transfer and to accurately document vital signs at the time of transfer. The resident had multiple significant diagnoses, including kidney failure, heart failure, epilepsy, COPD, and diabetes, and was documented as severely impaired for daily decision making and dependent in all ADLs and transfers. An SBAR completed for the resident’s transfer due to a low hemoglobin contained no vital signs or assessment data other than a prior weight from two days earlier. Nursing notes documented that an order was received to send the resident to the hospital for evaluation of an abnormal hemoglobin level of 6.5 and later that the resident had been sent out for low hemoglobin, but there was no documentation of an assessment at the time of transfer. Vital signs were recorded in the chart at 8:17 a.m. and 3:17 p.m. on the day of transfer, and an additional set of vitals was taken at 11:00 a.m. after dialysis, before the order to send the resident out was received. The record lacked documentation of the actual time the resident left the facility, and the DON reported that they could only infer the departure time from the census, which showed the resident removed at 12:17 p.m. The DON also confirmed that the vital signs documented as taken at 3:17 p.m. were entered hours after the resident had already left the facility and that the SBAR should have included a complete assessment and vitals at the time of transfer. The resident was later documented as admitted to the hospital with a hemoglobin of 6.2 and having received a blood transfusion.
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