Ruby Weston Manor, a nursing home facility located in Brooklyn, was cited in a May 2012 complaint survey by the Department of Health for failure to inform of accidents, significant changes, transfers, etc. According to the relevant parts of CFR section 483.10(b)(11), a facility “must immediately…notify the resident’s interested family member when there is…a decision to transfer or discharge the resident from the facility.” In the case of one resident at Ruby Weston, this was not done upon a hospital transfer.
The resident referred to in the report had several long-standing conditions, among which were several mental deficiencies, including dementia and depression. The resident also suffered from end-stage renal failure. During one particular dialysis session, the staff noted that the resident’s blood sugar was low and ordered a transfer to the hospital. When the transfer was made, the resident’s family was not notified. In fact, it was not until a relative of the resident visited the nursing home the next day that the family became aware that their loved one had been moved to the hospital.
This failure to notify violated both the relevant section of the CFR noted above as well as the nursing home’s own Policies and Procedures, which state that “Family Notification Form will be used to record the notification of families or designated representatives of significant events or issues regarding the care, condition or treatment of the resident.” Additionally, the facility’s Director of Nursing told the DOH that facility policy dictates that a resident’s family is to be notified when a transfer to the hospital occurs.
The DOH listed the severity of the incident as no actual harm, with potential for more than minimal harm. It does seem that the nursing home took the necessary precautions with respect to the patient’s treatment, sending her to the hospital when the circumstances warranted it. In such instances, though, the facility must provide the requisite follow-up to the family, and in that area, Ruby Weston came up short.
A full transcript of the Department of Health report can be found here.
