Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's change in condition and subsequent transfer to the hospital. The resident, who was cognitively intact and had multiple complex diagnoses including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and acute kidney failure, experienced a significant change in condition characterized by low blood pressure and altered mental status. Nursing staff assessed the resident and, following instructions from the on-call nurse manager, arranged for emergency transport to the hospital. However, there was no documentation or evidence that the resident's responsible party was notified of the change in condition or the transfer at the time it occurred. Interviews with the DON and nursing staff confirmed that the responsible party was not informed prior to or during the transfer, and the responsible party later reported not receiving any notification. The facility's policy required notification of the responsible party in the event of a significant change in condition, but this was not followed or documented in the clinical record. The deficiency was identified through staff interviews, clinical record review, and facility policy review, with no additional information provided by facility leadership during the survey.