Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition and transfer to the hospital, as required by facility policy. The facility’s policy N-105, “Notification of Change in Condition,” directs nursing staff to promptly notify the resident, attending physician, and resident representative when there is an accident, significant change in physical, mental, or psychosocial status, need to significantly alter treatment, or a transfer or discharge, and to document this notification in the medical record. The resident involved was admitted with diagnoses including surgical aftercare following digestive system surgery, disruption or dehiscence of an internal surgical wound, and a history of cardiac and vascular surgery with an aortocoronary bypass graft. A recent MDS showed the resident had normal cognition and required supervision or touching assistance for transfers and ambulation. On the evening in question, a progress note documented that the resident reported not feeling well for a couple of days, with ongoing bowel movements and feeling too unwell to go out to smoke. After the LPN checked the medication cart for GI-related orders, a CNA urgently summoned her; the resident was then found on the toilet, hunched over and being held up by another CNA. The LPN called a Code Blue, activated 911, and the resident was transferred to the hospital. A Change in Condition assessment completed after midnight documented “Unresponsiveness” but left the section for family representative notification blank, and a Transfer Assessment initiated the same date was also blank. There was no documentation in the clinical record that the resident’s representative was notified of the change in condition or transfer. The DON later stated that the hospital had informed the resident’s nephew (the representative) during the night, and that the nephew called the facility the next morning to ask what had happened. The DON acknowledged the Change in Condition form did not indicate emergency contact notification, and the LPN Unit Manager reported she verbally informed the representative the following morning but did not document this, leaving no record of timely notification at the time of the event.
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