Failure to Notify Family of Resident's Change in Condition and Hospitalization
Penalty
Summary
The facility failed to provide timely notification to a family member regarding a resident's change in condition and subsequent hospitalization. The resident in question was severely cognitively impaired and had diagnoses including cerebral infarction, quadriplegia, hypertension, and seizure disorders. Progress notes indicated that the resident experienced increased coughing and bleeding from the mouth, which led to a nurse practitioner being updated and new medication ordered. The following day, the resident's condition changed further, and the nurse practitioner ordered a transfer to the hospital for evaluation. Despite these significant changes, there was no documentation in the progress notes that the resident's family was notified about the change in condition, new orders, or the hospital transfer. During interviews, a family member confirmed she was not informed by the facility and only learned of the hospitalization from a hospital physician. The DON acknowledged that the family should have been notified prior to the transfer and confirmed that this did not occur. The facility was unable to provide a policy regarding notification of change in condition and transfer.