Failure to Notify Physician and Representative of Resident Status Changes and Transfers
Penalty
Summary
The facility failed to notify the physician and/or the resident's representative when there was a significant change in the resident's condition or when a transfer to the hospital occurred. For one resident with multiple chronic conditions, including diabetes, chronic kidney disease, atrial fibrillation, gout, and hypertension, there was no documented evidence that the physician or the resident's representative was notified when the resident was transferred to the emergency room. This was confirmed through record review and staff interview, which verified the absence of documentation regarding the required notifications at the time of transfer. In another case, a resident with diagnoses including Parkinson's disease, COPD, hypertension, GERD, pain, and edema experienced a significant change in condition that led to a hospital transfer and subsequent surgery for a perforated sigmoid colon. The responsible party had voiced concerns about the resident's status, and hospice staff were notified, but there was no documentation that the physician was informed of the change in condition prior to the transfer. Staff interviews confirmed the lack of physician notification and documentation regarding the resident's status change.