Failure to Notify Provider and Emergency Contact of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's provider and emergency contact (EC) of changes in condition and hospital transfers for one resident with multiple serious diagnoses, including acute respiratory failure, heart failure, kidney disease, and esophageal cancer. Record review showed that on several occasions, the resident was transferred to the hospital due to shortness of breath and low hemoglobin levels, as identified by the dialysis provider, but there was no documentation that the provider or EC was informed of these transfers. Additionally, when the resident developed moderate swelling in the left arm and was transferred to the hospital per provider's order, there was again no indication that the EC was notified. Interview with a registered nurse confirmed that the EC had not been contacted during these events, as required, and this was corroborated by the absence of documentation in the daily care notes. The deficiency was noted as a repeat from a previous survey, indicating a continued failure to communicate significant changes in the resident's condition and hospital transfers to both the provider and the EC.