Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s emergency contact of a significant change in condition, transfer to the hospital, and subsequent initiation of life-sustaining interventions. The resident had diagnoses including a personal history of transient cerebral ischemic attack (TIA) and seizure disorder. On the date of the incident, documentation showed the resident was observed by a CNA at approximately 5:00 a.m. and was up and talking at that time. Around 5:35 a.m., the resident’s roommate activated the call light and reported the resident was on the bathroom floor. The resident was found unresponsive with right-sided facial drooping and inability to raise the right arm, 911 was called, and the resident was transferred by ambulance to a local hospital emergency room. A Transfer to Hospital form listed the resident’s sister as the emergency contact and indicated she was not aware of the transfer, and the clinical record contained no documentation that the emergency contact was notified of the fall, acute change in condition, or hospital transfer. The resident’s family member, identified as the emergency contact, reported that she and the resident communicated often and that the family had planned to visit for the resident’s upcoming birthday. She stated she made three calls to the resident that day, each transferred to the nurse’s station without being answered, and on a fourth call around 9:00 p.m. a staff member informed her that the resident had been sent to a local hospital that morning and later transferred to a hospital in Indianapolis, where the resident was in the ICU on a ventilator receiving life-sustaining interventions. The family member stated that, in her opinion, the resident had suffered while alone in the hospital and that, had the facility contacted her as required, she might have been able to be present during his last lucid moments. The resident subsequently died without regaining consciousness. The facility’s own Notification of Change in Condition policy required prompt notification of the resident’s representative for significant changes in condition, life-threatening conditions, and transfers to the hospital, but this notification did not occur as required for this resident.
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