Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's designated representative of a change in the resident's medical condition and subsequent transfer to the hospital. The resident, who had a history of aphasia, experienced shortness of breath and was evaluated by a Certified Registered Nurse Practitioner, who recommended immediate diagnostic testing and medication. Documentation showed that the resident was notified of the change, but staff incorrectly recorded that the resident was their own representative, despite the baseline care plan and admission record listing another individual as the resident's representative. The resident's representative was not informed of the change in condition or the hospital transfer, and only learned of the hospitalization the following day. During an interview, the DON stated that staff are expected to notify representatives, but also indicated that if a resident can make their own decisions, staff do not notify the representative. There was no documentation to support that the representative was notified as required.