Failure to Notify Physician of Resident Hospital Transfer and Return
Penalty
Summary
The facility failed to notify the physician when a resident was transferred to and returned from the hospital. According to nursing progress notes, the resident's wife requested a hospital transfer and called 911, with facility staff only becoming aware when paramedics arrived. There was no documentation in the medical record indicating that the resident's physician was notified of either the transfer or the return from the hospital. Interviews with staff revealed that the nurse on duty was new and did not know to call the physician, instead contacting the previous Director of Nursing. Other staff confirmed that the expected procedure was to notify the physician and document the notification, but this was not done. The Director of Nursing and other staff stated that the facility's policy requires notification of the physician, family, and documentation of any significant change in condition, including hospital transfers. The physician confirmed that they were not notified and expected to be informed of such events. The facility's written policy also specifies that the primary physician should be updated about changes in condition, and if unavailable, the medical director should be contacted. The failure to notify the physician and document the notification represents a deviation from both facility policy and standard practice.