Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition and subsequent transfer to the hospital. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia/hemiparesis following a cerebral infarction, experienced new symptoms of right-sided numbness and weakness. Despite these symptoms and the resident's request to go to the hospital, there was no documentation that the responsible party was informed of the change in condition or the hospital transfer. Medical record review showed that the resident complained of numbness and weakness, and eventually left the facility via stretcher to the emergency department. The resident was later diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. Interviews with staff revealed that the LPN on duty was new and in orientation, and after consulting with the unit manager, called a physician and arranged for non-emergency transportation. However, there was no evidence in the medical record that the physician was contacted in a timely manner or that the responsible party was notified at any point during the incident. The facility's policy required prompt notification of the resident, physician, and representative in the event of a significant change in condition. Despite this, the documentation and interviews confirmed that the responsible party was not notified when the resident was sent to the hospital, and the physician's involvement was not clearly documented. This deficiency was identified during a complaint investigation and affected one resident reviewed for change in condition.