Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative when there was a significant change in the resident's physical status and when the resident was transferred to the hospital for treatment. The resident, who had diagnoses including cerebral infarction, glaucoma, vascular dementia, and anxiety disorder, was found slumped in a wheelchair after being outside in the courtyard. Staff noted the resident was unresponsive, with a high temperature of 107.5°F and an oxygen saturation of 88%. The resident was moved to an air-conditioned area, given oxygen, and ice packs were applied. Later, multiple blisters were found on the resident's arms and legs, which were treated and assessed by staff. Orders were obtained from a nurse practitioner for wound care, and the resident was eventually sent to the emergency room for evaluation approximately 24 hours after the incident. Despite these significant events, including the development of burns and the transfer to the hospital, there was no evidence that the resident's daughter, listed as the emergency contact, was notified by the facility. The daughter confirmed in an interview that she was not informed of the incident or the hospital transfer and only learned of the situation when contacted by the hospital. Facility policy required notification of the resident's representative in the event of significant changes or hospital transfers, but this was not followed in this case.