Failure to Promptly Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s legally designated representative of a significant change in condition and an emergency hospital transfer. Facility policy dated February 2024 required notification of the resident and/or representative for any significant change in condition, including hospital transfer. The resident had a Power of Attorney designation on file for a family member dated August 1, 2023. On January 9, 2025, at 9:31 a.m., a medical provider documented that an aide reported large amounts of blood on the floor, wheelchair, and bathroom floor. On evaluation, the resident was in bed with a blood-covered gown, dried blood on sheets, and a large amount of blood on the floor and wheelchair cushion, appearing awake, alert, weak, pale, and with some increased confusion, and was noted to have a rectal bleed. The provider reviewed the situation with the unit manager and agreed to transfer the resident to the emergency room for further evaluation. A nursing note authored by a licensed nurse at 4:02 p.m. the same day, approximately six hours after the change in condition and transfer, documented that the resident was sent to the hospital for rectal bleeding and transferred for gastrointestinal bleeding, and that the resident’s niece was contacted at that time to provide an update and address questions and concerns. The unit manager reported that she was on duty, received notification of the change in condition, contacted emergency services, and completed transfer paperwork, and stated that she believed the bedside nurse would notify the family. She confirmed that she did not speak with the family member until five to six hours after the transfer and then learned the representative had not been notified immediately. The bedside nurse confirmed she was assigned to the resident, responded to the room when called by an aide, and found the provider already assessing the resident and deciding on hospital transfer. She acknowledged it was her responsibility to notify the representative but assumed the unit manager had done so and did not verify that notification occurred. The Nursing Home Administrator confirmed there was a lapse in timely notification to the resident’s representative and a communication breakdown due to failure to clearly assign responsibility for notification.
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