Incomplete and Inaccurate Documentation During Resident Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident with dementia and a history of cerebral infarction who experienced an acute change in condition. The resident’s quarterly MDS showed moderate cognitive decline, and the care plan directed staff to assess for chest pain, shortness of breath, cyanosis, and to report changes to the physician. On the date of the incident, a progress note labeled as a change in condition documented that the resident was observed sitting in a wheelchair, pale and unresponsive, that the physician was notified, an order was obtained to send the resident to the emergency room, and that 911 was called. The note further stated that while awaiting EMS, the resident became alert and returned to baseline but was still sent to the emergency room. A concurrent review assessment by an LPN recorded vital signs and notification of the physician and responsible party regarding the transfer. During interviews and record review, the DNS confirmed there was no RN assessment documented prior to the transfer, despite an expectation that an RN assessment would be written in the progress notes and, if an LPN documented the assessment, the RN would sign it. The DNS also reported that the record lacked documentation of the exact time of the incident, EMS arrival and departure times, the resident’s state of alertness at the time of transfer, and any indication that a face sheet with diagnoses, medications, and pertinent data was sent with the resident or that the hospital emergency room was called with report. An LPN working the 3–11 shift stated that upon being notified the resident was unresponsive in a wheelchair, blood sugar was checked (within normal range), a sternal rub was performed with minimal response, and the resident was moved to bed and began to “come around,” while the RN supervisor remained at the nurses’ station making calls and preparing transfer paperwork. None of this LPN’s described evaluation and care was documented in the clinical record. Another RN recalled seeing the resident in the wheelchair starting to come to but could not remember details. These omissions occurred despite a facility policy requiring documentation of changes in condition, events, incidents, or accidents involving the resident.
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