Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident experienced a decline that led to a hospital transfer. The facility's policy required staff to inform both the physician and the resident's designated representative of any significant changes in condition or decisions to transfer. In this case, the resident, who had diagnoses including hypertension, depression, and dementia with moderately impaired cognition, became difficult to arouse and was subsequently transferred to the hospital. Documentation reviewed from the time of the incident did not show that the resident's representative was notified of the change in condition or the hospital transfer. Interviews with facility staff confirmed that the family was only informed after the resident returned from the hospital, at which point the family expressed upset at not being notified earlier. The Assistant Director of Nursing stated that the unit nurse was instructed to contact the family at the time of transfer, but there was no documentation to support that this occurred. The Director of Nursing also acknowledged that immediate notification of family members is required when there is a change in a resident's condition, but confirmed that the family was not informed until after the resident's return.