Failure to Immediately Notify Responsible Party of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident when there was a significant change in the resident's condition, a medication error, and a subsequent transfer to the hospital. The resident involved was an elderly female with severe cognitive impairment, Parkinson's disease, a hip fracture, type 2 diabetes, and dementia. Her care plan included medication management for Parkinson's disease. On the day of the incident, the resident experienced altered mental status and shortness of breath after a medication error, which led to her being transferred to the hospital. Documentation showed that the resident's emergency contacts were listed in her records, and facility policy required prompt notification of responsible parties following significant events such as medication errors or transfers. However, interviews with staff revealed that neither the charge nurse nor the ADON notified the responsible party at the time of the incident. The charge nurse assumed the ADON would make the notification, while the ADON believed it was the charge nurse's responsibility. Both staff members acknowledged that the responsible party was not informed until the following day, when they arrived at the facility. The responsible party confirmed during an interview that they were not notified of the medication error, change in condition, or hospital transfer until after the fact. Facility records and staff interviews consistently indicated that the required immediate notification did not occur, despite the facility's policy and the resident's need for such communication due to her cognitive impairment and medical condition.