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F0580
D

Failure to Notify Responsible Party of Resident Death

Sonora, California Survey Completed on 09-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately notify the responsible party (RP) or family member about the death of a resident who was under hospice care. The resident's contact list included seven individuals, with one family member designated as the RP. This RP was not contacted by the facility regarding the resident's passing; instead, she discovered the resident's death upon returning to the facility the following morning. The RP confirmed that neither she nor other family members were notified by the facility, and the hospice agency only contacted her after she arrived at the facility and learned of the death. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Service Assistant (SSA), and the Assistant Administrator (AADM), revealed inconsistent practices and expectations regarding notification of family members upon a resident's death. While some staff believed that hospice would notify the family, others stated that it was the facility's responsibility to ensure the RP or emergency contact was informed, regardless of hospice involvement. Documentation in the resident's medical record indicated that the family was present the night before the death, but this was confirmed to be inaccurate by both the RP and the ADON. A review of facility policies indicated that the nursing staff was required to notify hospice and the family in the event of a resident's death or change in condition. However, in this instance, the nurse contacted hospice but did not notify the RP or family, and there was no documentation of attempts to reach the RP or other contacts. The failure to notify the RP and family members directly violated the resident's right to have their responsible party informed of significant changes, including death.

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