Failure to Notify Physician and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify the appropriate physician and the resident's representative when a resident experienced a significant change in condition and required emergency transfer to the hospital. Specifically, a resident with chronic obstructive pulmonary disease and congestive heart failure was found to have altered mental status, shortness of breath, excessive sputum, and was unable to follow commands. Emergency Medical Services were called, and the resident was transferred to the hospital, where they required intensive care and intubation. However, the facility contacted the on-call provider for a different resident and did not notify the correct physician or the resident's representative about the change in condition or the hospital transfer. Record review and staff interviews confirmed that the progress notes and physician orders were incorrectly documented for another resident, not the one who was actually experiencing the emergency. The resident's representative was not informed of the transfer, and the hospital was given incorrect patient identifiers. The Director of Nursing and the Administrator were unable to provide evidence that the correct notifications were made as required. The deficiency was identified through review of records, interviews with staff and resident representatives, and cross-referenced with related deficiencies.