Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to ensure timely notification of resident representatives or emergency contacts when two residents were transferred to the hospital. In the first case, a resident with end stage renal disease, respiratory failure, and atrial fibrillation was sent to the hospital for perma-catheter placement and later admitted for hypotension and end stage renal disease. Although the resident's family member was listed as the emergency contact, there was no documented evidence that the representative was notified at the time of transfer. The resident reported that their family was not contacted until days later, and documentation showed that the family member was only called after the resident returned to the facility. In the second case, another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia was admitted to the hospital for medical issues. The family member, listed as the emergency contact, stated they were not notified by the facility and only learned of the hospitalization from the hospital itself. There was no documentation of representative notification in the medical record. Facility policy required timely notification of residents and their representatives regarding transfers or discharges, but this was not followed in these instances.