Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding the reasons for two unplanned hospital transfers for a resident who was severely cognitively impaired. Record review showed that the resident was transferred to the hospital on two separate occasions and returned to the facility after each event. There was no documentation in the medical record indicating that the resident's representative was notified in writing of the reasons for these transfers. Staff interviews revealed that the Administrator had previously handled these notifications during the Social Worker's leave but ceased doing so upon the Social Worker's return, without informing the Social Worker that this responsibility had shifted back. As a result, the resident's representative was not notified by mail for either hospital transfer.