Failure to Notify POA of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's power-of-attorney (POA) of significant changes in the resident's condition and subsequent transfer to the hospital. The resident, who had diagnoses including cognitive communication deficit, altered mental status, mood disorder, major depressive disorder, dementia, and Alzheimer's disease, experienced a change in mental status characterized by increased confusion, refusal of care, hallucinations, and agitation. Despite these changes and the eventual transfer to the emergency room as ordered by the physician, there was no documented evidence that the resident's POA was informed at any point during these events. Staff interviews confirmed that the facility's policy required prompt notification of the resident's representative in the event of a change in condition or transfer to a hospital. Both the LPN Unit Manager and the Director of Nursing acknowledged that the POA was not notified as required. Review of the facility's policy further supported the expectation for such notifications, but documentation and staff statements indicated this did not occur for the resident in question.