Failure to Notify Resident Representative of Hospital Transfer After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of a transfer to the hospital following a change in condition. Facility policy dated 09/16/2016 required that proper notification of a transfer or discharge be made to the resident and/or representative, including the reason for the transfer, with documentation in the clinical record, and that in an emergency transfer the representative receive written notice within 24 hours. The resident involved had diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, and hypertensive heart disease with heart failure, and physician orders dated 04/11/2025 included monitoring vital signs every shift, metoprolol tartrate for hypertension and heart failure, and lorazepam as needed for anxiety. On 04/12/2025, nursing documentation showed the resident’s pulse was initially 101 and irregular, then later increased to 153, prompting notification of the RN Nursing Supervisor and administration of metoprolol. When the heart rate remained elevated at 140, lorazepam was given, and the on‑call medical provider was contacted. The provider instructed staff to send the resident to the hospital, and the RN Nursing Supervisor documented that the resident was transported to the emergency room for tachycardia. There was no documentation that the resident’s designated representative was notified of the transfer. In interviews, the RN Unit Manager stated representatives should be notified the day a change in condition occurs but was unsure if this resident’s representative had been notified, and the RN who arranged the transfer recalled sending the resident out and speaking with the provider but did not recall speaking with the representative, stating they believed the RN Nursing Supervisor would notify the representative and that such notification should be documented in the chart.
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