Failure to Notify Responsible Party of Resident Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party following a significant change in the resident's condition that resulted in a hospital transfer. The facility's policy requires immediate notification of the resident, physician, and legal representative or family member when there is a significant change in the resident's status or a decision to transfer or discharge. In this case, a resident with severe cognitive impairment, multiple psychiatric diagnoses, and an active Durable Power of Attorney (DPOA) was transferred to a psychiatric center for evaluation due to agitation and physical behaviors. Documentation showed that the family was not informed of the transfer at the time it occurred. The resident's family member, who was the active DPOA, only learned of the transfer after calling the facility the following morning. Interviews with facility staff, including the Social Service Director, DON, and administrator, confirmed that nurses are expected to notify families and document such notifications, but there was uncertainty and lack of clarity regarding responsibility for ensuring this process was completed. The LPN involved stated that they may have forgotten to document the notification, and the DON acknowledged responsibility for oversight of this process.