Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that responsible parties were notified of a change in condition for one resident. According to facility policy, a nurse is required to notify the resident's representative within twenty-four hours of a change in the resident's medical or mental condition, unless otherwise instructed by the resident. In this case, a resident with diagnoses including atrial flutter, epilepsy, nutritional disorder, and chronic kidney disease, and with moderately impaired cognition, was sent to the emergency room following a physician's order. Documentation showed that the resident was admitted to the hospital with an acute cerebrovascular accident. Despite the facility's policy, there was no documentation in the resident's progress notes indicating that the family representative was notified of the hospital transfer. The family representative confirmed they were not informed by facility staff and only learned of the transfer from the medical flight transport pilot. The LPN involved acknowledged the lack of notification and documentation, and the DON confirmed that the family was not notified by staff at the time of the transfer.