Failure to Ensure Nursing Staff Competency During Emergency Transfer
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to meet resident needs during an emergency transfer. Specifically, an LPN incorrectly identified a resident experiencing a significant change in condition and reported the wrong resident to the on-call provider. The LPN also sent the incorrect medical record and patient identifiers with the resident during transfer to the hospital, resulting in the hospital treating the resident under another individual's information for approximately two hours. The facility's policy required nursing staff to collect and organize pertinent information and accurately report the resident's current symptoms and status to the physician, which was not followed in this instance. The resident involved had a history of chronic obstructive pulmonary disease and congestive heart failure and was admitted to the hospital's Intensive Care Unit requiring intubation after presenting with altered mental status, excessive sputum, and cool skin. The LPN did not provide a verbal report to the hospital at the time of transfer, and the Director of Nursing Services was unable to provide evidence that the LPN was competent with the facility's protocol for acute condition changes. This series of actions and omissions resulted in the resident being at risk for delayed or inappropriate treatment.