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Based on interview, record review and document review, the facility to follow established policies and procedures in regards to notification of the patient's responsible party (POA) of a significant change and deterioration in the patients health status. (Patient #1)

Findings include:

The complainant and responsible party reported the facility failed to provide notification regarding a significant change and deterioration in the patients condition over a two day period on 11/04/11 and 11/05/11. The facility failed to provide notification in a timely manner when the patient suffered a cardiac arrest at the facility and was transferred to an acute care hospital.


A Physician History and Physical dated 09/30/11 indicated the patient was a 51 year old male who was admitted to the facility on 09/30/11 after being stabilized at an acute care hospital for a diagnosis that included acute cerebrovascular accident involving middle cerebral artery. The patient had altered mental status, upper and lower extremity weakness. The patient's diagnoses included acute kidney injury, oropharyngeal dysphagia, persistent bacteremia, hypertension, possible endocarditis and protein C and S deficiency for which the patient was on anticoagulation therapy with Lovenox and Coumadin therapy. Lab reports dated 10/30/11 indicated the patient tested positive for clostridium difficile.

Medical records documented the patients sister was listed as the person legally responsible for the patient. (Power of Attorney)

A Discharge summary dated 12/07/11 indicated on 11/04/11 the patient appeared dehydrated, pale and sick and was refusing to eat. The patient was refusing blood work and was receiving intravenous fluids. On 11/05/11 the patient complained of lower abdominal pain, looked tired and pale and was having diarrhea. A blood transfusion was ordered for volume depletion. While nurses were trying to type and cross match blood the patient suffered a cardiac arrest. Emergency Services (911) was called and the patient was transferred to an acute care hospital for further management. The patient passed away on 11/05/11 at the acute care hospital. The cause of death was listed as sudden death, etiology unknown. Cardiac arrest.

There was no documented evidence in the physician progress notes or nursing notes that the patients sister (responsible party) was notified of the patients deteriorating condition over a two day period on 11/04/11 and 11/05/11 prior to the patient suffering a cardiac arrest and being transferred to an acute care hospital.

The facility's Communications of Unanticipated Outcomes Policy and Procedure last reviewed 07/11 included the following:

Policy: Patients and, when appropriate, their families will be informed about the outcomes of care, including unanticipated outcomes. Only the physicians and or his/her designee may inform the patient/family of an unanticipated outcome.

Definition: Unanticipated Outcome: Unanticipated outcomes may include the following:

1. Transfer to an acute care setting.
2. Injury to a patient while in a restraint.
3. Patient fall which may or may not result in an injury.
4. Major change in a patient's condition.
5. Moderate to severe patient's reaction to a medication/blood transfusion.

The nursing staff will notify the physician of unanticipated outcomes.

The responsibility of notification of the patient or family may be delegated to the nurse for the following:

1. Transfer to an acute care setting.
2. Injury to a patient while in a restraint.
3. Patient fall which may or may not result in an injury

On 12/06/11 at 2:00 PM an interview was conducted with the CNO (Chief Nursing Officer) who acknowledged the patients physician documented the patients condition had deteriorated on 11/04/11 and 11/05/11 and the patient was reported as looking sick, pale and dehydrated and was having diarrhea stools. The patient had been refusing antibiotic and anticoagulant medication and was refusing a blood draw to be typed and cross matched for a blood transfusion. The CNO acknowledged the patients sister who was designated as the responsible party and POA was not called and notified of the patients deteriorating condition by the facility. The CNO acknowledged the facility staff attempted to call the responsible party after the patient suffered a cardiac arrest and was transferred to an acute care hospital but was unable to reach the responsible party by phone or leave a message about the patients condition.

Complaint # 29806