Delayed Response to Resident's Change in Mental Status
Penalty
Summary
The facility failed to act timely on a change in mental status for Resident #11, who was observed experiencing visual hallucinations and delusions. On 4/9/2025, the resident reported seeing cats on her dresser, which she described as resembling wolves. This was a new onset for the resident, who had no prior history of delusions or visual hallucinations. Despite the resident's ability to communicate her needs and the presence of a major depressive disorder among her diagnoses, the facility did not address these symptoms promptly. The resident's hallucinations were first noted on 3/31/2025, when a CNA reported the resident talking about seeing live rats, but no immediate action was taken. The delay in addressing the resident's change in condition was further highlighted by the Nurse Practitioner's documentation on 4/1/2025, which noted the resident's confusion and visual hallucinations but did not result in further assessment or monitoring. It was not until the survey process on 4/9/2025 that the facility began to take steps to address the issue, including initiating a behavior log and planning a medical workup. This lack of timely intervention represents a deficiency in the facility's response to a significant change in the resident's mental status.