Failure to Notify Resident's Representative of Hospital Admission
Penalty
Summary
The facility failed to notify a resident's representative of a hospital admission, resulting in a deficiency related to notification of changes. The resident in question had a history of severe cognitive impairment, as evidenced by a BIMS score of 6, and multiple complex medical diagnoses including post-surgical amputation care, type 2 diabetes with neuropathy, severe malnutrition, osteomyelitis, and local skin infection. Despite these conditions and the resident's inability to make informed decisions, the facility did not inform the designated representative or family member when the resident was transferred to the hospital for a procedure and subsequently admitted as an inpatient. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for notifying the family. The DON acknowledged that residents with severe cognitive impairment should have their family or POA notified of significant changes, such as hospital admission. The Social Service Director confirmed that POA paperwork had been completed by the resident's wife, but it had not been filed due to pending additional signatures. The transportation staff, who were involved in taking the resident to the hospital, stated that notifying family was not within their job responsibilities and expected nursing staff to handle such communication. The family member only learned of the hospitalization through a call from the hospital social worker, not from the facility. Documentation review showed that the facility had a policy requiring appropriate documentation and notification during transfers or discharges, but there was no evidence that the resident's representative was contacted regarding the hospital admission. The resident's admission record listed the wife as the emergency contact, and the POA document was present but not reflected in the admission record. The lack of timely notification and documentation of the hospital transfer constituted the deficiency identified by surveyors.