Failure to Protect Resident from Neglect Following Request for Hospital Transfer
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to protect a resident's right to be free from neglect. The resident, who had a history of acute embolism, thrombosis, atrial fibrillation, chronic pulmonary edema, and peripheral vascular disease, reported to the RN that he needed to go to the hospital due to leg pain and shortness of breath. The RN did not perform an assessment, did not notify a physician or another licensed nurse, and did not facilitate the resident's transfer to the hospital. Instead, the RN called the police to report the resident's behavior, omitting the resident's request for hospital transfer. When the police arrived, the RN again failed to inform them of the resident's request to go to the hospital. The police, upon interacting with the resident and noting his symptoms, called EMS, who then transported the resident to the emergency room. The resident was subsequently admitted to the hospital and placed on a heparin drip as a precaution for possible deep vein thrombosis (DVT), pending further tests. Interviews and record reviews confirmed that the RN did not communicate the resident's request or change in condition to the appropriate medical personnel, and other staff members did not immediately report the neglect to facility leadership as required by policy. The resident was cognitively intact and able to communicate his needs, including his desire to be sent to the hospital. Multiple staff interviews corroborated that the RN had a pattern of avoiding care for this resident and delegating medication administration to other nurses. The failure to assess, notify, and act on the resident's request for hospital transfer constituted neglect, as the resident's medical needs and rights were not addressed in a timely or appropriate manner.