Failure to Monitor Resident's Condition Leads to Hospitalization
Summary
Complaint #2025003458 was substantiated with a citation at N201, and Complaint #2025002491 was substantiated with citations at N201 and N204. A male resident was admitted to the facility with a condition related to prostatic hyperplasia. On a specific morning, the resident's condition was not adequately monitored after a change in his medical device, leading to a lack of output being observed. Later that day, the device was removed due to no output, and the resident experienced a significant medical event involving copious amounts of fluid and clots. The facility failed to monitor the resident's condition, including vital signs, which resulted in the resident being emergently transferred to the hospital. Upon arrival at the hospital, the resident was unresponsive to painful stimuli, had low blood pressure, and a fever, leading to intubation and hospital admission. The facility's failure to adequately monitor the resident with a significant change in condition resulted in neglect and created a likelihood of serious harm or injury.
Penalty
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