Failure to Notify Provider of Resident Change in Condition Prior to ER Transfer
Penalty
Summary
Facility staff failed to notify the resident's provider when there was a significant change in condition for a resident with complex medical needs, including a recent digestive system surgery, peritoneal abscess, malignant carcinoid tumor, and a colostomy. The resident was transferred to the emergency room (ER) and subsequently to a higher-level care hospital due to hypotension and altered mental status related to severe sepsis. Documentation in the electronic health record did not show that the provider was contacted prior to the resident being sent to the ER, nor was there documentation explaining the reason for the transfer or who authorized it. Interviews with facility staff, including an RN, LPN, DON, and the nurse practitioner, confirmed that the provider was not notified as required. The resident's family member also reported that the resident appeared unwell days prior to the transfer and that staff were made aware of the resident's declining condition. Facility policy and staff statements indicated that the provider should have been notified either before or immediately after the resident was sent to the ER, but this did not occur.