Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) when a decision was made to transfer a resident to the hospital. According to the facility's policy, both the resident and their representative must be informed prior to any transfer, including the reason for the transfer, in a manner they understand. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 3 out of 15 and diagnoses including diastolic heart failure, severe vascular dementia, and diabetes, was transferred to the hospital due to breathing issues. The RP was not informed of the transfer by the facility and only became aware when contacted by the hospital. Interviews with staff revealed that the RN assigned to the resident on the day of transfer was under the impression that the unit manager (UM) was responsible for notifying the RP and handling the required paperwork. The UM, who is no longer employed at the facility, could not be reached for clarification. Both the interim DON and the administrator stated that their expectation was for staff to follow the policy and notify the RP with any transfer, but this did not occur in this instance.