Failure to Notify Responsible Party of Change in Condition and Emergency Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) for a resident who experienced a change in condition and was sent to the emergency room. Specifically, after the resident had an unwitnessed fall, the facility did not contact the RP until the following day, despite having received written instructions with updated after-hours contact information. Instead, staff left multiple voicemails on the RP's office phone, which was only checked during regular business hours. The updated contact information, which included specific after-hours instructions, was not added to the resident's admission record, resulting in staff being unable to reach the RP in a timely manner during an emergency. Interviews with facility staff confirmed that the updated contact information was received but not incorporated into the resident's records. The facility's policies required immediate notification of changes in condition and documentation of such notifications, but these procedures were not followed. As a result, there was miscommunication between the facility, the RP, and the emergency room, and medical decisions were made for the resident without input from the RP.