Failure to Notify Emergency Contact of Resident Hospitalization
Penalty
Summary
The facility failed to notify the designated emergency contact of a significant change in condition for a resident who experienced a fall resulting in hospitalization. The resident had multiple diagnoses, including a femur fracture, hemiplegia, and other mobility impairments, and was dependent on staff for care. Documentation reviewed, including the SNF/NF to hospital transfer form, SBAR Communication Form, and Progress Notes, did not show evidence that the family member or emergency contact was notified of the resident's transfer to the hospital. Interviews with the resident and her family member confirmed that the family was not informed by the facility and only learned of the hospitalization from the resident herself, after the fact. Staff interviews revealed that while the RN notified the DON and the physician about the resident's change in condition and subsequent transfer, there was no documentation or confirmation that the family was contacted. The DON acknowledged that facility policy requires staff to notify the resident's representative in the event of a significant change and to document this notification in the medical record. A review of the risk event note with the DON confirmed the absence of documentation regarding family notification. The facility's policy also specifies that such notifications and documentation are required.