Failure to Notify Family and Provider of Resident’s Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family and the on-call provider of a significant change in condition that resulted in the resident being sent to the hospital. The resident had multiple serious diagnoses, including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed severe cognitive impairment with a BIMS score of 3/15 and dependence on staff for toileting and perineal hygiene. The resident’s wife had previously expressed concerns about his safety and care, including that his call light did not work and that the bell provided as an alternative could not be heard because he was at the end of the hall. A nursing progress note documented the wife’s complaint that it was neglectful that no one could hear when he needed help and that she believed he had received the worst care there. On the day of the change in condition, the resident’s family member noticed he was responding differently and questioned a decline in his condition. She reported that the LPN caring for him told her he was not dying and, when asked if he should go to the hospital, stated that the hospital would not do anything but send him back. The family member requested that staff check his vital signs, and when the resident appeared to perk up somewhat, she left for the day. Later, the hospital contacted her to inform her that the resident had been there for several hours. The family member reported that the facility had not called her about this change in condition and that there were no missed calls or messages on her cell phone or home landline. She was very upset that she was not notified, particularly after having earlier asked the LPN whether he should be sent to the hospital.
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