Failure to Notify Legal Guardian of Resident's Death
Penalty
Summary
The facility failed to notify the legal guardian of a resident's death in a timely manner, as required by facility policy. The resident, who had diagnoses including Alzheimer's disease with late onset, unsteadiness, and hyperlipidemia, was admitted with the Public Administrator's Office listed as the legal guardian and primary contact. On the day of the resident's death, progress notes documented the resident was actively dying, received comfort medications, and passed away with a relative and hospice nurse present. However, there was no documentation that the legal guardian was notified at any point during or after the resident's passing. Interviews revealed that staff believed hospice was responsible for notifying the legal guardian, especially since a relative was present at the bedside. Hospice staff stated they only notify the legal guardian if no family is present, and in this case, did not make the notification. The facility's charge nurse and other staff did not contact the legal guardian, and the Director of Nursing and Assistant Director of Nursing also believed hospice had handled the notification. The Social Service Director claimed to have reached out to the legal guardian but later it was determined that no contact was made. As a result of the lack of notification, the business office was also not informed of the resident's death in a timely manner. The Business Office Manager, who was on vacation, processed a check from the legal guardian's office two weeks after the resident's death, unaware of the passing. The legal guardian's office only learned of the resident's death during a routine monthly visit, and no paperwork or direct communication from the facility was received regarding the death.