Failure to Notify Resident Representatives of Significant Condition Changes and Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify residents’ representatives of significant changes in condition and transfers to the emergency department, as required by facility policy and 42 CFR §483.10(g)(14). For one resident (R1), who had multiple medical diagnoses including diabetes, heart disease, urinary retention, history of prostate cancer, and a left leg amputation, progress notes documented a change in condition with altered mental status, poor intake, and functional decline. The physician was notified and ordered stat labs and increased fluids, and later directed that the resident be sent to the emergency department when the resident’s oxygen saturation dropped to 81%, blood pressure to 62/40, and the resident could not keep fluids down. The resident was transferred to the hospital and diagnosed with septic shock and Fournier’s gangrene, both described as life-threatening conditions. There was no documentation that the resident’s family or emergency contact was notified at the time of the change in condition or transfer, and a family member later reported being upset that they were not updated until almost 6:00 AM the following day. For another resident (R2), who had diagnoses including weakness, stroke, diabetes, obstruction/reflux uropathy, and aphasia, progress notes showed the development of severe abdominal pain and subsequent lab results indicating elevated white blood cell count. The physician was notified and, due to severe abdominal pain and acute leukocytosis with concern for progression of sepsis, ordered the resident sent to the emergency department. The resident’s face sheet specifically directed staff to update the resident’s sibling if the resident went to the ER, but surveyors found no evidence in the medical record that the emergency contact was notified of the transfer. Interviews with an LPN and the DON confirmed that there was no documentation of family notification for these hospitalizations, despite facility policy requiring documentation of notification of the responsible party, including date, time, and content of the communication each time they are notified.
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