Failure to Inform Resident of Laboratory Results and Treatment Decisions
Penalty
Summary
The facility failed to ensure that a resident was fully informed of her laboratory bloodwork values and the reasons for her transfer to the hospital for a transfusion, as well as her lab results after returning from the hospital. Despite facility policy requiring residents to be notified of their medical condition and any changes, there was no documentation that the resident or her legal representative was informed of her critically low hemoglobin (HGB) levels or the specific reason for her hospital transfer. Nursing progress notes indicated that the physician and family were notified of the transfer, but did not mention informing the resident herself about her lab results or the rationale for the transfer. The resident, who was cognitively intact and had diagnoses including anemia, chronic heart failure, and chronic respiratory failure, reported that she was not told her bloodwork values either before being sent to the hospital or after her return. Staff interviews confirmed that it was the responsibility of nursing staff to inform residents of significant changes in their condition, but there was no evidence in the medical record that this communication occurred. The DON also could not recall specifically discussing the resident's HGB levels with her.