Failure to Notify Resident Representatives of Significant Changes and Hospital Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition, as required by both facility policy and the Nursing Home Residents' Rights. In the case of one resident with multiple complex medical diagnoses, including sepsis, paraplegia, and end stage renal disease, there were two separate hospital transfers due to acute changes in condition. Documentation showed that the resident's mother, who was the designated representative, was not notified of either transfer. This was confirmed by both the resident and the mother, who expressed distress at not being informed. Nursing staff interviews confirmed that it was their responsibility to notify family or representatives, but there was no documentation of such notifications for these events. Another resident, with diagnoses including diabetes insipidus, traumatic brain injury, neurocognitive disorder, and cancer, was transferred to the hospital after removing sutures from a surgical site, resulting in bleeding. This resident had a legal guardian, as documented in the medical record. However, there was no evidence that the guardian was notified of the incident or the subsequent hospital transfer. The guardian reported only learning of the transfer when contacted by the hospital for necessary paperwork. Nursing staff again confirmed their responsibility to notify representatives, but no documentation of notification was found. Review of facility policy and residents' rights documents indicated that representatives should be informed of significant changes in health status, including hospital transfers, as soon as possible or within 12 hours. Despite these requirements, the facility did not document or provide evidence of timely notification to the appropriate representatives in these cases, resulting in a deficiency related to communication and notification of significant changes.