Failure to Immediately Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) when a resident experienced a significant change in condition and was sent to the hospital. The resident, who had a history of nontraumatic intracerebral and intracranial hemorrhage, type 2 diabetes mellitus, dysphagia, dementia, and hemiplegia/hemiparesis, was noted to have severely impaired cognition. On the date of the incident, the resident was found to have an altered level of consciousness, was difficult to arouse, non-verbal, and had minimal response to stimuli. The physician was notified and ordered the resident to be sent to the hospital for evaluation. Although the House Nursing Supervisor attempted to call the RP to notify them of the transfer, no one answered, and it was unclear if a voicemail was left. The supervisor became occupied with another emergency and did not make further attempts to contact the RP that day. The following morning, the supervisor tried again and learned that the hospital had already notified the RP about the transfer the previous evening. The Director of Nursing confirmed that the RP should have been notified at the time of the transfer.