Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change in condition and subsequent transfer to the hospital. According to the facility's Charge Nurse Workflow, the RP should be notified when a change in condition is identified. In this case, a resident with moderately impaired cognition, as indicated by a BIMS score of 12, exhibited increased psychosis, including threatening behavior and verbal outbursts. The progress note documented that the RP was notified of the situation and the decision to transport the resident, and that the nurse practitioner was also informed. However, interviews and record reviews revealed that the Director of Health Services (DHS) contacted the resident's daughter, listed as the emergency contact, rather than the Department of Human Services representative who was documented as the actual RP. The DHS stated she used the information from the resident's dashboard, which did not reflect the correct RP. The actual RP reported that she was not made aware of the resident's hospital transfer until contacted by the resident's daughter several days later. This failure to notify the correct RP was identified for one of three residents reviewed for notification of change.