Failure to Follow Physician Orders and Hospice Agreements During Resident Transfers
Penalty
Summary
The facility failed to follow physician orders and hospice agreements for two residents, resulting in significant lapses in care. One resident, who had a diagnosis of cerebral infarction and was on hospice care with a DNR/DNI status, was mistakenly sent to the emergency room for evaluation and treatment of low blood pressure and low oxygen saturation. The hospital identified that the wrong patient had been sent, and the resident was returned to the facility without receiving treatment. The family was not notified prior to the transfer, and the hospice provider was only informed after the incident. The facility did not have a physician order to send this resident to the hospital, and the hospice agreement specifically required prior approval before any transfer, which was not obtained. Another resident, who had been admitted with diagnoses including Human Metapneumovirus and SIRS, experienced a temperature elevation, abnormal lung sounds, and a significant drop in blood pressure. The medical director ordered this resident to be transferred to the hospital for further evaluation. However, due to an error, the resident was not sent to the hospital as ordered. The oncoming nurse reassessed the resident and decided to manage the symptoms at the facility without consulting the medical director or following the original transfer order. The resident's family was notified after the decision not to transfer was made. Interviews with staff revealed confusion and lack of clarity regarding the transfer process, with agency CNAs unfamiliar with resident names and roles. The facility's own policies and the hospice agreement required notification and coordination with hospice and family prior to any transfer, which did not occur in these cases. Documentation confirmed that the wrong resident was sent to the hospital and that a resident who should have been transferred was not, both in direct violation of physician orders and established protocols.