Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition and subsequent transfer to the emergency department (ED). The resident, who had intact cognition and diagnoses including coronary artery disease, heart failure, and hypertension, experienced acute symptoms such as diaphoresis, pallor, chest pain, coughing with bloody sputum, wheezing, shortness of breath, and weakness. The physician on call was notified and recommended transfer to the ED. The resident was transferred by wheelchair once a driver became available. Despite facility policy requiring notification of the resident's representative in the event of a significant change or transfer, the representative was not informed prior to the transfer. The transfer notice was not signed by the resident, and the representative only learned of the transfer upon arriving at the facility to visit. Interviews with both the representative and the DON confirmed that no phone call or paperwork regarding the transfer was provided to the representative.