Failure to Notify Family of Resident Death
Penalty
Summary
The facility failed to notify the resident representative of a significant change in a resident's status, specifically failing to inform the family when a resident expired. The resident, a female with diagnoses including malignant neoplasm of the brain, epilepsy, and altered mental status, was on hospice care at the time of her death. Documentation showed that the resident was found without respirations, and hospice was notified. The hospice nurse reportedly instructed the facility nurse not to notify the family until hospice arrived. The nurse did not notify the family, nor did he follow up to ensure the family was informed. The facility's progress notes did not document any further communication with the family, and the time of family notification was unclear in hospice records. Interviews revealed that the nurse typically would notify the family immediately but deferred to hospice's instructions in this instance. The DON was uncertain about the facility's policy regarding family notification when hospice was involved and assumed hospice had reasons for delaying notification. The hospice representative stated that hospice would never instruct a facility not to notify next of kin and considered immediate notification important. Facility policies reviewed required immediate notification of family or representatives in the event of significant changes, including death, but this was not followed in this case.