Failure to Immediately Notify Resident's Representative After Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's representative after the resident was found unresponsive in the spa tub and transferred to the emergency department via EMS. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and a history of mental health conditions, was assessed as having intact cognition and required partial to moderate assistance with bathing. On the evening of the incident, the resident was discovered unresponsive but breathing, and EMS was called to transport the resident to the hospital. Documentation shows that the facility provided a report to the emergency department nurse and noted the transfer, but there is no evidence that the resident's emergency contact was notified at the time of the incident. Interviews with the resident's family member revealed that they were unaware of the incident or the resident's hospitalization until contacted by the surveyor several days later. The family member reported not receiving any information from the facility despite multiple attempts to obtain updates, and only received limited information after speaking with the nursing home administrator days after the event. The registered nurse involved in the incident confirmed that the emergency contact was not notified, and the administrator could not confirm that timely notification had occurred. This sequence of events demonstrates a failure to immediately inform the resident's representative of a significant change in the resident's condition and transfer to the hospital.