Failure to Notify Resident Representative of Significant Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition and transfer to the hospital, as required by facility policy. The resident was an older adult female with multiple diagnoses including cerebral infarction with aphasia, type 2 diabetes mellitus, primary hypertension, congestive heart failure, and stage 3 chronic kidney disease. Her MDS showed a BIMs score of 00, indicating she could not complete the mental status interview. She had been admitted to the facility the prior evening, and her representative and another family member visited her shortly after admission. On the morning following admission, at approximately 6:00 a.m., a CNA arriving on the unit observed the resident’s bathroom light on and found the resident seated on the commode, leaning backward. The CNA reported the resident was able to communicate but could not state how she got to the bathroom. When the CNA attempted to assist her to stand with one-person assistance, the resident staggered backward, so the CNA returned her to a seated position on the commode and called for help. Staff obtained a wheelchair and assisted the resident back to bed. Later that morning, at approximately 7:45 a.m., a therapist reported to an LVN that the resident was minimally responsive and breathing abnormally. The LVN assessed the resident and found her hyperventilating, not verbally responsive but making eye contact, with vital signs including pulse 100, respirations 24, temperature 97.7°F, blood glucose 371, oxygen saturation 91% on room air, and an unmeasurable manual blood pressure; the resident was diaphoretic and cold to the touch. The LVN notified the provider of the change in condition and received an order to send the resident to the emergency room, and the resident left the facility with EMS at approximately 8:00 a.m. in stable condition. Review of the medical record showed no documentation that the resident’s representative or family was notified of the change in condition or the transfer. The resident’s representative later stated he was not notified by the facility and only learned of the transfer when another family member arrived at the facility and discovered the resident was not in her bed, at which time staff informed that family member of the transfer. The ADON and RNC both stated that facility policy requires notification of the resident’s representative for significant changes in condition and documentation of that notification in the medical record, and they could not confirm that notification occurred because there was no documentation. The facility’s written policy on change in a resident’s condition or status states that the facility promptly notifies the resident, attending physician, and resident representative of changes in the resident’s medical or mental condition and/or status.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.