F0550

D

Failure to Honor Resident’s Request for Emergent Hospital Transfer and Lack of Assessment/Documentation

Glendale, Arizona Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency centers on the facility’s failure to honor a cognitively intact resident’s right to self-determination regarding an emergent transfer to the hospital, and to appropriately assess and document his condition when he requested to go to the emergency room. The resident had multiple significant diagnoses, including type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, pulmonary hypertension, anemia, and a left below-knee amputation. A recent MDS showed a BIMS score of 13, indicating intact cognition, and there was no documentation of a medical power of attorney or court-appointed decision-maker, meaning the resident was his own decision-maker. In the days leading up to the incident, provider notes documented worsening renal function, acute kidney injury on chronic kidney disease stage III, metabolic acidosis, suspected dehydration, and the need for urgent nephrology follow-up. Orders were written for a nephrology appointment “as soon as possible,” a BMP, and sodium bicarbonate for metabolic acidosis, as well as a Foley catheter to evaluate for outlet obstruction versus neurogenic bladder.

On the date the resident requested to go to the hospital, the clinical record contained no nursing progress notes, no documented nursing assessment, and no documentation of the resident’s request or concerns. There was also no evidence that vital signs (blood pressure, oxygen saturation, pulse, respirations, or temperature) were assessed or recorded that day, despite the resident’s ongoing acute medical issues and new orders. The MAR/TAR for that date was blank for the Foley catheter order, and there was no documented change-of-condition monitoring for that date or the following day, even though additional orders were in place for labs and treatment related to acute kidney injury and metabolic acidosis. Staff interviews indicated that CNAs and LPNs had observed that the resident was not doing well in the days before his death, including increased pain with turning, pallor, frequent lab draws, and plummeting renal function.

On the day in question, the resident called a friend stating he was not feeling well, felt the facility was not doing enough, and that he had told the nurse he wanted to go to the emergency room but was told he did not meet criteria and would not be sent. The friend reported calling the resident’s floor nurse, who reiterated that the resident did not meet criteria for a 911 transfer and that the doctor would not authorize a hospital transfer. The friend then called 911 and was connected to the fire department, which later cancelled its response after speaking with the nurse, who stated there was no physician order and the resident did not meet criteria to be sent out. The nurse later told the provider that the resident’s desire to go to the hospital was due to dissatisfaction with the food, and no other concerns were relayed. Multiple staff, including the RN, ADON, and DON, stated there was no formal list of criteria for emergent transfer and acknowledged that residents have the right to choose to go to the hospital, yet one LPN stated she was not allowed to call 911 or decide on transfers, and another LPN believed she could not assist a resident in calling 911. The facility had no policy on emergent hospital transfer, and existing policies on resident rights, change of condition reporting, and vital signs required honoring resident rights, assessing and documenting changes in condition, and taking vital signs as warranted by the resident’s condition, which were not followed in this case.

Subsequently, a nursing note documented that a nurse entered the resident’s room to administer medications and found him unresponsive and not breathing, with no vital signs, and confirmed DNR status before pronouncing him deceased. Interviews with CNAs and LNAs described the resident as not behavioral, not prone to overreacting, and generally not someone who asked for much, which they felt made his request to go to the hospital significant. The ADON and DON both stated they were not aware of the incident involving the resident’s request to go to the hospital or the fire department contact. The facility’s own policies on resident rights and change of condition, along with federal regulation 42 CFR § 483.10, were cited in relation to the failure to ensure the resident’s right to self-determination and to appropriately assess, document, and respond to his request for emergent hospital transfer.