Failure to Notify Representatives and Physicians of Resident Status Changes
Penalty
Summary
The facility failed to notify the designated representatives and physicians of two residents regarding significant changes in their status, specifically related to hospital transfers. One resident, who was severely cognitively impaired and had a diagnosis of cerebral infarction and facial weakness, was mistakenly sent to the emergency room due to low blood pressure and low oxygen saturation. Although documentation indicated that the resident's power of attorney and the medical director were notified, interviews revealed that the power of attorney was not informed until two days later by a hospice nurse, and the medical director was not notified at all. The hospice nurse also confirmed delayed notification. In a separate incident, another resident, who was cognitively intact and had diagnoses including Human Metapneumovirus and SIRS, was reportedly not transferred to the hospital as initially planned. The resident's daughter was not informed by the facility about the transfer status and only learned through a hospital inquiry that her mother was not at the hospital. The medical director was also not informed that the resident had not been sent out as ordered and only discovered this during a routine visit. Facility policies require timely notification of residents, families, and physicians regarding transfers, but these procedures were not followed in these cases.