Failure to Address Resident's Change in Condition Resulting in Death
Penalty
Summary
The facility failed to provide the highest practicable care for a resident, identified as Resident CR1, whose change in condition was not adequately addressed, resulting in the resident's death. Resident CR1, a long-term resident, began experiencing nausea and vomiting on a specified date, but there was a lack of documentation and follow-up on the resident's condition over the subsequent days. The resident's meal intake significantly decreased, and they experienced loose stools, yet these changes were not communicated effectively to the resident's physician or physician assistant (PA). The PA was not informed that the resident's symptoms began earlier than reported, and there was no evidence that the PA or physician was made aware of the resident's low blood pressure or the extent of the resident's condition. Despite orders for diagnostic tests and medication, these were not completed before the resident's condition worsened. The resident was eventually sent to the emergency department but expired before arrival. The report highlights a lack of timely and effective communication and documentation regarding the resident's change in condition. The facility staff did not provide evidence that the resident's healthcare providers were adequately informed of the resident's symptoms and declining condition, which contributed to the resident's death. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Corrective action cannot be achieved for resident CR1. 2. All residents have the potential to be affected. Facility has implemented monitoring of nurse's documentation to identify affected residents who have had a significant change in condition thru review of nursing notes and vital sign logs. Nursing will assess residents with a significant change in condition and notify the physician of findings. 3. Education will be provided to medical providers and nursing staff using a program developed by a well-established center of geriatric health service education, and will include a review of all the federal regulations cited along with a review of the accompanying guidelines for F-0684, and any changes to facility policies and procedures. 4. DON or designee will audit 10 residents with change in condition for proper assessment, intervention, notification and documentation weekly x 4 then monthly x 3. Results of audit will be reviewed with QAPI process and meetings.