Failure to Notify Family of Resident Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s emergency contacts when the resident was transferred to the hospital on two separate occasions. The resident had chronic obstructive pulmonary disease, congestive heart failure, and chronic renal failure, with a low cognitive function and dependence on staff for activities of daily living. Her care plan noted behavior problems, including physical and verbal abuse toward staff and refusal of treatments. Contact information in the record showed that the resident was her own responsible party, with one daughter listed as the first emergency contact and authorized HIPAA contact, and another daughter listed as an additional emergency contact. Facility policy required that, unless otherwise instructed by the resident, a nurse would notify the resident’s representative when it was necessary to transfer the resident to a hospital or treatment center. On the first incident, respiratory therapy documentation showed that during routine rounding the resident’s SpO2 was 84% on six liters of oxygen, with intermittent jerking of extremities, drowsiness, and minimal response to stimuli. Despite suctioning and ventilator adjustments, her SpO2 dropped to 74–85%, leading staff to initiate manual bag ventilation and call emergency medical services, who then transferred her to the hospital. A progress note documented hospitalization for sepsis due to a urinary tract infection but contained no evidence of family notification. On the second incident, respiratory therapy notes documented that the resident was lethargic compared to her usual anxious, energetic behavior, with SpO2 in the low 80s on six liters of oxygen, requiring an increase to 10 liters to reach 94%, and edema in her fingers. EMS was again called and the resident was transferred to the emergency department, but the medical record and quality improvement tools for both transfer dates were void of any documentation that her emergency contacts were notified. Staff interviews, including with the DON, confirmed the expectation that families should be notified and verified the absence of such documentation for both transfers.
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