Failure to Honor Advanced Directives Leads to Unnecessary Hospital Transfer
Penalty
Summary
A resident with a diagnosis of cerebral infarction and facial weakness, who had a care plan and POLST indicating a preference for comfort-focused treatment and limited hospital transfers, was mistakenly sent to the hospital. The resident's care plan specifically directed that hospital transfer should only occur if comfort could not be achieved in the facility. On the date of the incident, there were no documented vital signs or medical symptoms for the resident, and no nurse's progress notes indicated any concerns. A late entry in the nurse's notes later clarified that the resident was sent to the emergency room due to low blood pressure and low oxygen saturation, but this was a case of mistaken identity; another resident was actually intended to be transferred. Interviews with facility staff confirmed that the resident did not require outside intervention and that the transfer was not medically necessary. The Director of Nursing was unable to explain how the resident was taken by emergency medical technicians without the duty nurses' knowledge. The resident underwent unnecessary diagnostic testing at the hospital before the error was discovered. Facility policy requires that services be provided to maintain residents' physical and mental health and satisfaction, but in this case, the resident's advanced directives and care preferences were not honored.