Failure to Notify Family of Resident's Change in Condition and Hospital Transfers
Penalty
Summary
The facility failed to ensure that a resident's family or responsible party was notified of multiple changes in the resident's condition, as required by facility policy. Medical record review for a resident with diagnoses including end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation showed several instances where the resident was sent to the hospital or returned to the facility without documentation that the family was informed. Specific nurse notes indicated the resident was transferred to the hospital or returned to the facility on multiple occasions, but there was no evidence in the electronic medical record that the family was notified at any of these times. An interview with the unit manager LPN confirmed that there was no documentation of family notification for any of the hospital transfers or returns. The facility's policy on resident change in condition requires prompt notification of the resident, attending physician, and responsible party when there is a change in the resident's condition or status. The lack of documentation and failure to notify the family of these significant events constituted non-compliance with the facility's own policy.