Failure to Notify Responsible Party of Resident Transfer and Hospital Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all required notifications regarding a resident's transfer and discharge were made. The resident in question had multiple diagnoses, including hyperlipidemia, bipolar disorder, anxiety disorder, and gastro-esophageal reflux disease, and had a public fiduciary listed as the responsible party, guardian, and emergency contact. Documentation reviewed showed that while a discharge assessment indicated the responsible party was notified, it did not specify who was notified or when. There was no documentation in the order summary report or progress notes indicating that the responsible party was informed of the resident's transfer to the hospital or subsequent admission. Further review revealed that the resident was transferred to the emergency room due to COVID-19 symptoms and low oxygen saturation, and was admitted to the hospital for a prolonged stay. The resident did not return to the facility until over two weeks later. During this period, there was no evidence in the medical record that the public fiduciary was notified of the transfer or hospital admission. A complaint was submitted to the State Agency by the responsible party, stating that they were not informed of the resident's transfer until a care conference, and that the facility did not accurately communicate the resident's status. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the standard practice is to notify the responsible party or public fiduciary prior to a resident's transfer and to document this notification in the medical record. The staff acknowledged the importance of this communication and indicated that failure to notify is inappropriate. Facility policy also requires documentation of notification to the resident and/or legal representative when a transfer or discharge occurs, including in emergency situations. However, in this case, the required notifications and documentation were not completed.