F0842

D

Failure to Document Resident Change in Condition and Emergency Transfer

Weimar, Texas Survey Completed on 03-30-2026

Penalty

Fine: $15,920

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records and incident/change-of-condition documentation for a resident who experienced a significant change in condition and was transferred to the hospital. The resident was an elderly female with dementia, muscle wasting, gait abnormalities, and muscle weakness, who had an ADL self-care deficit and communication problems but was usually understood and usually understood others. Her Quarterly MDS showed a BIMS score of 4, indicating impaired cognition. The care plan identified limited physical mobility and use of antidepressant medication with risk for side effects. The resident’s face sheet showed she had been admitted to the facility with no discharge date recorded at the time of review.

Family members and staff provided differing accounts of the events leading up to the resident’s transfer. One family member reported receiving a call from an LVN stating the resident had stroke-like symptoms and was sent to the ER, and later learned from the hospital that the resident had a stroke and was med-flighted to a higher level of care. This family member stated that the LVN told her the resident had shown stroke-like symptoms for about 24 hours without the family being notified, and that the LVN had instructed another nurse to monitor the resident for stroke-like symptoms before going off shift. The LVN reportedly told the family member she called 911 against facility protocol and was terminated for sending the resident to the ER without prior physician consent. The family member also stated that no one from the facility had officially notified her of the resident’s discharge with a change in condition or checked on the resident’s status.

Multiple staff interviews showed that the resident’s change in condition and subsequent transfer were not properly documented in the clinical record. The HS reported being informed by the LVN that a med aide had observed the resident in and out of consciousness, but the HS questioned how the resident could have been unconscious for two shifts without any reports. LVN C stated that when a med aide relayed family concerns that the resident was not feeling well, she assessed the resident, found vital signs normal, and the resident stated she was fine; she then told the oncoming LVN to watch for changes. The med aide reported that during an evening medication pass, the resident was asleep, did not receive medications, and a family member expressed concern about the resident’s appearance; the med aide noted the resident appeared asleep with some whites of her eyes visible, asked a CNA about the resident’s status, and informed LVN C and then LVN D about the missed medications. The med aide stated there was a rumor that a family member spoke to LVN C about the resident’s condition and that no one checked on the resident for 12 hours, and that when LVN A came on shift, the resident’s blood pressure was 181/131, prompting the LVN to call 911.

The interim DON stated that on the day of the change in condition, the resident required immediate transfer by ambulance to a higher level of care, and that as the resident’s nurse, LVN A should have completed an SBAR/change-of-condition report documenting the date, time, assessment findings, vital signs, medications, and notifications to the physician and family. The interim DON confirmed there was no SBAR, no discharge summary, and no nursing progress notes detailing or summarizing the resident’s need for hospital transfer or her condition at the time of transfer, and that the absence of the SBAR also affected the resident’s appearance on the ADT list and initiation of the discharge summary. The administrator reported that when a family member requested the resident’s clinical records, he could only provide the last hospital notes in the progress notes and that he did not have more detailed information because he had not obtained it from staff. He further stated that LVN A had not completed the required change-of-condition/SBAR documentation describing when, where, and why the resident was sent to the hospital. Physician documentation showed that a provider had assessed the resident the day before the event and noted no issues, and that later, the physician was informed by LVN A that the resident had elevated blood pressure and eyes rolling back, and directed the nurse to call 911 for immediate transfer due to stroke-like symptoms. The discharge summary for the resident was only completed and signed several days later, after surveyor intervention, confirming that the facility failed to contemporaneously document the resident’s change in condition and transfer in accordance with professional standards and regulatory requirements.

The facility’s own admission, transfer, and discharge log reflected that the resident was discharged to an acute care hospital on the date of the change in condition, but the clinical record at that time lacked corresponding nursing notes, SBAR, or timely discharge summary documenting the resident’s status, assessments, and notifications. Staff interviews consistently indicated that LVN A, as the charge nurse, was responsible for completing the change-of-condition documentation and that this was not done. The interim DON acknowledged that it was the DON’s responsibility to ensure the charge nurse completed the SBAR and that the process “fell through” and the discharge was not reviewed. As a result, the resident’s clinical record did not contain complete and accurate information about the change in condition, the care provided, or the notifications made at the time of the emergency transfer, which the report states had the potential to affect all residents by compromising continuity of care, clinical decision-making, and resident safety.