Failure to Escalate Care for Resident with Acute Condition
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center failed to provide timely and appropriate care to a resident who experienced a significant change in condition. The resident, admitted with diagnoses including muscle weakness and hypertension, showed signs of acute kidney injury and metabolic abnormalities, as evidenced by laboratory results and vital signs. Despite these indicators, the facility did not conduct timely monitoring or escalate care appropriately. The resident's condition deteriorated, with symptoms such as lethargy, diaphoresis, and poor oral intake, yet there was no documented escalation of care or transfer to a hospital. On January 5, 2025, the resident's vital signs indicated a concerning change, including low blood pressure and elevated heart rate, but no interventions were documented at that time. The following day, intravenous fluids were initiated, but the resident's condition continued to decline. By January 7, 2025, the resident was found unresponsive and later pronounced deceased after CPR was attempted. Interviews confirmed the facility was aware of the resident's condition change but failed to provide necessary interventions or hospital transfer, resulting in a missed opportunity to address the resident's acute medical needs.
Plan Of Correction
1. Resident R1 no longer resides in the facility. 2. Current residents identified as having a change in condition in the past 7 days have had their records reviewed to ensure timely interventions have been initiated as applicable. 3. The DON/Designee will reeducate licensed nurses to the facility Change in Resident Condition or Status policy. 4. The DON/Designee will audit random audit progress notes weekly x 4 weeks, then monthly x 2 months to ensure resident changes in condition have applicable interventions or transfer to higher level of care. Audits will be presented to the QA Committee for review and follow-up as needed.