Failure to Honor Guardian’s Right to Decide on Hospital Transfer After Fall
Penalty
Summary
Facility staff failed to honor the right of a resident’s court-appointed guardian to make decisions regarding transfer to the hospital. The resident had an MDS completed showing a BIMS score of seven, indicating severe cognitive impairment, and a court order documented that the resident was an incapacitated person with the son designated as permanent guardian and responsible party. After the resident, who required an assistive device and one-person assistance, attempted to self-transfer and was found on the floor, staff completed assessments and documented no injuries. Staff left a message for the responsible party about the fall and later documented that the responsible party returned the call and had no questions at that time. Subsequently, 911 dispatch contacted the facility to report that the resident’s responsible party had called 911, stating the resident had fallen and needed to be checked. Facility staff reported to 911 that the resident was being monitored per protocol and that the resident denied pain, and no EMS dispatch or hospital transfer occurred. There was no documentation of any follow-up or attempted communication from facility staff to the resident’s responsible party after the 911 call to discuss the resident’s condition or the guardian’s expressed desire for emergency services or hospital transfer. The record contained no evidence that staff provided the resident’s responsible party the opportunity to exercise the right to have the resident transferred to the hospital as requested.
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