Failure to Notify Legal Guardian of Resident's Refusal for Hospital Transfer
Penalty
Summary
The facility failed to communicate with a resident's Legal Guardian regarding the resident's abdominal pain and the resident's refusal to go to the hospital. The resident, who had a history of hypertensive heart disease with heart failure, diabetes mellitus type 2, dementia, and hypomagnesemia, was admitted with a court-appointed Legal Guardian responsible for making medical decisions. On the day of the incident, the resident complained of mild abdominal pain and was initially agreeable to hospital evaluation but later refused. The nurse, assessing the resident as alert and oriented, did not inform the Legal Guardian of the resident's refusal or the change in condition, instead proceeding with labs and x-rays at the facility as ordered by the Nurse Practitioner. Subsequent staff interviews revealed that the Legal Guardian was not notified of the resident's abdominal pain or refusal to go to the hospital on the day it occurred. The following day, the resident's condition worsened, and the nurse on duty notified the Legal Guardian about the transfer to the emergency room and the events of the previous day. The Legal Guardian expressed that he should have been contacted earlier, as he was responsible for medical decisions and believed the resident would have followed his advice to seek hospital evaluation. Interviews with facility leadership, including the DON and Administrator, confirmed that the resident was not capable of making his own medical decisions and that the Legal Guardian should have been contacted regarding the refusal of hospital transfer. The failure to notify the Legal Guardian prevented the representative from exercising the resident's rights as required.