Failure to Notify Resident Representatives of Hospital Transfer
Penalty
Summary
The facility failed to notify the designated resident representatives of a significant change in condition and subsequent transfer to the hospital for one resident. According to facility policy, notification of a resident's family or representative is required as soon as possible, and no later than 24 hours after a significant change is identified. In this case, the clinical record for a resident with Alzheimer's disease and severe cognitive impairment (unable to complete the BIMS interview) showed that the resident required a proxy for decision-making. The resident's son, daughter-in-law, and another son were listed as emergency contacts and representatives. Documentation review revealed that the Change in Condition Evaluation form was left blank, and the Transfer to Hospital form incorrectly indicated that the resident herself was the representative notified. Progress notes only documented that the son was informed after the resident had already been admitted to the hospital, with no evidence that emergency contacts were notified at the time of the change in condition or transfer. The Nursing Home Administrator and DON confirmed that the required notifications were not made for this resident.