Failure to Notify Guardian of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's legal guardian of a significant change in condition and subsequent transfer to a hospital. The resident, who had diagnoses of schizophrenia and major depression and was under the guardianship of a Public Administrator, experienced behavioral issues that led to a decision by facility management to send the resident to the hospital. Documentation showed the resident was admitted to the hospital and remained there for several days, but there was no record of the guardian being notified of the change in condition or the hospital transfer. The facility's policy required prompt notification of the resident's legal representative in such situations. Interviews with staff revealed that the LPN responsible for the resident's care assumed that an orientee had notified the physician and guardian and documented the incident, but this was not confirmed or recorded. The orientee, who was new and on their first day, was unsure if the guardian had been contacted. The DON and Administrator acknowledged that the required notifications and documentation were not completed as per facility protocol. The deficiency was identified through review of records and staff interviews, which confirmed the lack of timely notification to the resident's guardian.