Failure to Timely Assess and Escalate Care for Resident
Penalty
Summary
Dunmore Health Care Center was found to be non-compliant with professional standards of nursing care as outlined in 42 CFR Part 483 Subpart B. The deficiency was identified during an Abbreviated Complaint Survey, which revealed that the facility failed to conduct and document a thorough nursing assessment following a change in condition for a resident. The resident, who was admitted to the facility with aphasia and cognitive impairment, experienced a significant change in condition when her daughter reported concerns about her being clammy and lethargic, with an oxygen saturation level of 87%. Despite the presence of an RN supervisor, there was no documented evidence of a completed assessment at that time. Further review showed that there was a delay in addressing the resident's condition, as no additional documentation was made until the following morning when another RN noted the resident's condition had not improved and contacted the physician. Although STAT labs were ordered and returned with results indicating an elevated white blood cell count consistent with an active infection, the resident was not transferred to the hospital until several hours later. The resident was subsequently diagnosed and treated for sepsis. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the failure to timely assess and escalate care, resulting in a lack of nursing services consistent with professional standards.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #1 no longer resides at the community. Employee #2 provided 1:1 education on resident assessment post change in condition by the DON/Designee. To identify like residents that have the potential to be affected, the DON/Designee conducted a 2 week look back of nursing progress notes and 24 hour reports to validate that a thorough and timely nursing assessment was conducted post change in condition. To prevent this from happening again, the DON/Designee will educate the licensed nurses on recognizing and intervening in the event of change in resident condition. The registered nurse will be educated on conducting and documenting a timely assessment and follow-up when a change in condition is identified. The education will be completed by 2-6-25. To prevent this from happening again, the Regional Nurse will educate the Interdisciplinary team on reviewing changes in condition at morning meetings to ensure compliance. The education will be completed by 2-6-25. To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with changes in condition per week for 4 weeks, then monthly for 2 months to ensure professional standard of practice and timely follow-up. Results of audits will be submitted to the QAPI committee for further review and recommendation.