Failure to Address Change in Condition Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure proper care and services were provided after a change in condition for two residents, leading to severe consequences. Resident 4 experienced a significant decline in health, with symptoms including low blood oxygen levels and difficulty breathing, which were not promptly addressed by the nursing staff. Despite the resident's oxygen saturation dropping to critical levels, the Licensed Practical Nurse (LPN) on duty did not notify the Registered Nurse (RN) supervisor or the attending physician, resulting in the resident's condition worsening to the point of requiring an emergency hospital transfer. Upon arrival at the hospital, Resident 4 was found to be in a critical state, suffering from cardiac arrest and subsequently passing away. Resident 5, who had a history of pneumonitis, antimicrobial resistance, and COVID-19, also experienced a change in condition that was inadequately managed. The resident's oxygen saturation levels dropped significantly, and although supplemental oxygen was administered, there was no evidence that the RN was informed or that a proper assessment was conducted. Additionally, the resident's medication administration record showed no documentation of nebulizer treatments or supplemental oxygen being administered as ordered, indicating a lapse in following the prescribed care plan. The failure to notify the RN supervisor and/or the attending physician of the changes in condition for both residents placed them and other residents on the unit in an Immediate Jeopardy situation. The lack of timely medical intervention and proper documentation contributed to the deterioration of the residents' health, highlighting significant deficiencies in the facility's adherence to care protocols and communication procedures among the nursing staff.
Plan Of Correction
1. Facility cannot retroactively address changes in condition for Residents #4 and 5. 2. Facility wide audit was completed on 12/6/24 of current residents by review of the facility's 24-hour shift report to ensure that any resident with a change in condition has had an RN assessment completed and documented with notification of the physician and responsible party as appropriate. 3. Education was provided to employee 4 verbally on 11/27/24 and in written form on 12/2/24. Education has been given to licensed nursing staff on change in condition protocol including the need for LPNs and RNs to notify the RN supervisor. RN assessment will be conducted. Physician and resident representative notification and MD orders. Any new/agency staff will be educated on the same protocol. Licensed staff will review the 24-hour shift report as part of the shift-to-shift report to ensure any resident change in condition has been properly followed up on to include RN assessment and required notifications. Directed in-service has been scheduled for December 26, 2024 for licensed nursing staff. This directed in-service will be taped for education purposes. 4. The Director of Nursing/Designee will review the 24-hour shift report for any changes in condition and will ensure that an RN assessment, responsible party, and physician notification was completed weekly for four weeks then monthly for two months and ongoing as needed. Results of audits will be reviewed by QAPI committee for compliance and recommendations.
Removal Plan
- Education was provided to Employee 4 verbally and in written form.
- Education has been given to licensed nursing staff on change in condition protocol including the need for LPNs and RN's as charge nurses to notify the RN Supervisor immediately, including Physician notification and orders. Any New/Agency Staff will be educated on the same protocol on arrival.
- Facility wide audit will be completed of current residents by review of the facility's 24 hour shift report to ensure that any resident with a change in condition has had an RN assessment with notification of the physician.
- Every shift the Director of Nursing or designee will review the 24 hour shift report for any changes in condition and will ensure that an RN assessment and physician notification was completed for four weeks.