Failure to Honor Resident's Right to Self-Determination and Timely Hospital Transfer
Penalty
Summary
A deficiency occurred when a cognitively intact male resident, who was his own responsible party and had a significant medical history including acute embolism, thrombosis, atrial fibrillation, and chronic pulmonary edema, requested to be sent to the hospital due to worsening leg pain and shortness of breath. The resident had a documented history of deep vein thrombosis (DVT) and was at high risk for further complications. Despite his request and his ability to make his own medical decisions, the assigned RN did not facilitate his transfer to the hospital or notify the physician or Director of Nursing (DON) about his request or change in condition. The RN entered the resident's room after being informed that he wanted to speak with her. Upon being told by the resident that he needed to go to the hospital, the RN responded that he could go, but did not proceed with any assessment, further questioning, or initiation of the transfer process. The interaction escalated, resulting in the resident becoming verbally aggressive and the RN leaving the area and calling the police due to concerns for her safety. The RN did not inform the police, other staff, or facility leadership that the resident had requested to go to the hospital. The police, upon arrival, observed the resident's symptoms and contacted EMS, who then transported the resident to the hospital for evaluation and treatment. Interviews with facility staff, including the DON and other nurses, confirmed that the RN failed to notify appropriate personnel or take action to address the resident's request and symptoms. The DON was not made aware of the situation until days later, and the resident's physician stated that the nurse should have contacted EMS for transport as per protocol. The facility's policy on resident rights, which includes the right to self-determination and participation in care decisions, was not followed in this instance, resulting in a failure to honor the resident's rights and potentially compromising his dignity and quality of life.