Failure to Notify POA of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident who was transferred to the hospital. The resident, who had diagnoses including chronic kidney disease stage 4, chronic obstructive pulmonary disease, chronic diastolic heart failure, and iron deficiency anemia, was admitted to the facility and later transferred to the hospital. The medical record indicated that the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required varying levels of assistance with activities of daily living. A review of the resident's closed record showed that the POA was listed as the emergency contact. However, documentation revealed that when the resident was transferred to the hospital, the POA was not notified as required by facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged that the notification should have occurred. The facility's policy, revised in May 2017, states that a nurse will notify the resident's representative when a transfer to the hospital is necessary.