Failure to Document and Address Changes in Resident Conditions
Penalty
Summary
The facility failed to document nursing staff's response to reported changes in condition for two residents, leading to deficiencies in care. Resident #46 experienced multiple instances where staff observed and reported changes in his condition, such as increased assistance needed for transfers, shortness of breath, and confusion. Despite these observations, there was a lack of documented nursing evaluations or actions taken in response to these reports. The Director of Nursing acknowledged the absence of documentation and noted that the resident should have been assessed and the physician notified. Resident #66 also experienced a deficiency in care when she requested to be transferred to the hospital due to nausea and vomiting. Despite her request and symptoms, RN Staff X did not contact the physician or document an assessment. The resident's condition worsened, and she was eventually transferred to the hospital the following day after being seen by a practitioner. The Risk Manager was unaware of the incident until later, and RN Staff X was suspended pending investigation. Both cases highlight a failure in the facility's process for addressing and documenting changes in residents' conditions. The lack of timely nursing assessments and communication with physicians contributed to delays in appropriate care and interventions for the residents involved.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #66 and resident #46 are no longer in the facility. B. PTA staff F, COTA staff Y, LPN staff W, staff AA, CNA staff N, RN staff R, PTA staff Z, Evening supervisor RN staff B, RN staff X, LPN staff M was educated on F684. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A complete audit of residents with a change of condition and residents requesting to go to the hospital was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Licensed nurses were educated on resident requests to be sent to the hospital and documentation of change in condition. B. Nursing managers will review the 24-hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken, including but not limited to sending the resident out to the hospital. C. All concerns of change in condition will be brought to the morning meeting for follow-up by the nurse management team. D. Licensed nurses will document and assess any concerns brought to them by any staff members regarding a change in condition, and they must notify the physician in a timely manner to obtain further interventions. If nurses are unable to get ahold of the physician, they can contact the medical director. In an emergent case, such as distress, licensed nurses will call 911 and have the resident sent to the hospital, then document entirely on the findings and interventions. E. Staff will use the INTERACT Stop and Watch program/form to relay any change in condition noted by any resident at the facility. A copy of the Stop and Watch form will also be brought to the morning clinical meeting to be reviewed by nurse managers/ADT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit the follow-up for any change of condition or request to go to the hospital to ensure timely assessment, documentation, and notification is obtained. The audit communication for change in condition will occur weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance, and Compliance Committee monthly for one quarter.