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Based on interviews and record review, the facility failed to ensure a patient's family member was promptly notified when the patient expired for 1 (Patient #4) of 3 patients reviewed for changes in condition. This failure had the potential to affect all patients.

Findings included:

Review of the facility's policies revealed the facility had no policy that addressed notification of a patient's family/responsible party at the time of a patient's death.

Review of a "History and Physical" revealed the facility admitted Patient #4 on 02/04/2022.

Review of a "Flowsheet," dated 02/04/2022, revealed the admitting physician (Physician #4) notified the family member via telephone of Patient #4's admission.

Review of a consent form revealed verbal consent for the admission was received from Patient #4's family member via telephone on 02/04/2022.

Review of nursing notes, dated 02/11/2022, revealed Patient #4 was unresponsive upon return from radiology and was found to have no pulse or respirations. The notes indicated Physician #2 was notified of Patient #4's condition and pronounced Patient #4's time of death at 11:10 AM. There was no evidence the physician notified the patient's family member of Patient #4's death.

Review of the face sheet in Patient #4's medical record revealed the "Emergency Contact Phone Number" did not have the correct area code; however, the correct number was observed to be listed at the top of the same Face Sheet. Additionally, the correct phone number was listed on the admission paperwork from the assisted living facility from which the patient transferred. The correct phone number was also listed on the Emergency Medical Transport paperwork. Patient #4's electronic medical records revealed the patient had previous visits to the hospital, with the correct telephone number listed on the records from those visits.

During a telephone interview on 11/09/2022 at 12:30 PM, Registered Nurse (RN) #7, who was working on 02/11/2022 at the time of Patient #4's death, stated Patient #4 was transported to x-ray for magnetic resonance imaging (MRI) and upon return, the transport staff reported the patient was not able to move from the stretcher to the hospital bed. RN #7 stated she went to check on Patient #4 and saw the patient had passed away. RN #7 notified Physician #2, and the patient was pronounced by the physician at 11:10 AM. RN #7 stated she informed Patient #4's family member when they arrived for visitation, prior to the family member entering the patient's room. RN #7 stated the physician normally spoke with family. RN #7 was unable to explain why the physician did not speak with Patient #4's family member to inform them of Patient #4's death.

During a telephone interview on 11/09/2022 at 10:30 AM, Physician #2, who pronounced Patient #4's death on 02/11/2022, stated he spoke with Patient #4's family member at the bedside on 02/09/2022 and explained Patient #4's poor prognosis. Physician #2 stated attempts were made to call the family member when the patient died, but the phone number was not working. Physician #2 stated he did not speak with the family member about Patient #4's death and did not recall being notified when the family member arrived for visitation.

During an interview on 11/09/2022 at 9:30 AM, Physician #4 (accompanied by his supervisor, Physician #3) revealed hospitalists worked 12-hour shifts and worked seven days on and seven days off. Physician #4 admitted Patient #4 and provided care for the patient on 02/04/2022 through 02/07/2022. Physician #4 stated he called the patient's family member on 02/04/2022 to gather information at the time of admission but did not recall how he got the phone number.

During an interview on 11/09/2022 at 9:00 AM, RN #5 indicated she was working on 02/11/2022 when Patient #4 expired but was not providing care for Patient #4. She stated she did go to Patient #4's room with the assigned nurse, who reported the patient came back from having an MRI and was observed to be expired upon return. RN #5 stated she listened to Patient #4's chest with her stethoscope and did not hear any heartbeat. RN #5 indicated the physician (Physician #2) was notified, and Patient #4 was pronounced at 11:10 AM on 02/11/2022. RN #5 stated the assigned nurse attempted to call the family, but the call did not go through, so the nurses watched the elevator and waited for the family member to arrive for visitation. RN #5 stated the pastoral service talked with the family member as well. RN #5 gave no explanation as to why the assigned nurse did not inform the physician (Physician #2) of the family member's arrival and stated, "The primary nurse should have called the physician to come and talk with the [family member]."