Failure to Notify Resident’s Guardian of Death
Penalty
Summary
The facility failed to notify a resident’s state-appointed guardian of a significant change in status, specifically the resident’s death, for one of four residents reviewed. The resident’s face sheet identified a state guardian as the resident representative. Nursing documentation showed that the resident expired during the night with family and a hospice nurse present at the bedside, and that the body was later picked up by a funeral home. However, there was no documentation in the resident’s progress notes that the guardian was notified of the death, nor any additional entries regarding the death beyond the initial note. Interviews with facility staff and hospice personnel confirmed that the guardian was not notified. An LPN stated that when a resident dies, the nurse is responsible for notifying the physician, the resident’s POA, emergency contacts, and guardian if applicable, and for documenting the time of death and who was notified in the progress notes. The DON similarly stated that upon a resident’s death, nursing must notify hospice if applicable, emergency contacts/POA or guardian, and the physician, and document these notifications. The hospice director reported that a hospice nurse was present at the time of death but was new, lacked access to the electronic medical record, and did not think to ask about additional emergency contacts or a guardian; there was no hospice documentation that the guardian was notified. The facility’s Change of Condition policy requires notification of the responsible party for changes in condition, but this did not occur for the resident’s guardian in this case.
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