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Based on facility document review, staff interviews and review of the facility's policy and procedure for transferring patients, it was determined the facility failed to ensure each patient's next of kin or designated representative was notified when initiating a transfer of a patient on 1 of 10 sampled patient (Patient #4).

The findings included:

Medical record reviews conducted on 05/02/17, the patient was transferred from the 4th floor to the 5th floor, to be monitored on the telemetry unit, a higher level of care. The receiving nurse noted the patient was alert and oriented and her call light was within reach. The record failed to reveal the patient's family or responsible party was notified.

Interview with the Chief Nursing Officer, on 08/22/17 at approximately 3:32 PM, revealed when they transfer patients to another room on the same floor, they do not notify the patient's family or responsible party. When they transfer a patient to a different floor or when the patient has experienced a change of condition, they notify the patient's family or responsible party.

Review of the Policy & Procedure for Transferring a Patient reveals the patient's family will be notified when the patient is transferred to a higher level of care.

Interview with the Director of Progressive Care and Telemetry Units, on 08/24/17 at approximately 2:00 PM, he stated they transferred the patient to the telemetry unit to be monitored more closely and regularly. He confirmed the record did not indicate the patient's family or responsible party was notified of the patient's transfer to the 5th floor telemetry unit.