Failure to Respond to Resident's Request for Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of acute recurrent sinusitis, shortness of breath, hemiplegia, and hemiparesis requested to be sent to the hospital due to not feeling well. The resident, who had intact cognition as indicated by a BIMS score of 12, used her call light multiple times to inform a CNA of her request to go to the hospital. The CNA reported the request to the LVN on duty, but the LVN did not promptly assess the resident or arrange for her transfer. The resident continued to request assistance over several hours, but no nurse evaluated her or addressed her concerns during that time. There was no documentation in the progress notes or vital sign log regarding the resident's request or any assessment on the day in question. The resident ultimately contacted her significant other to take her to the hospital after several hours without nursing intervention. Upon evaluation at the hospital, she was diagnosed with a urinary tract infection and acute inflammation of the air passages and was prescribed antibiotics. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's repeated requests, and the DON was not aware that the resident had initially asked staff to be sent to the hospital. Facility policy states that residents have the right to request treatment or care, but in this instance, the resident's request was not addressed according to professional standards or her expressed wishes.