Failure to Monitor Resident's Condition Leads to Deficiency
Penalty
Summary
The facility failed to appropriately assess a resident experiencing changes in condition, leading to a deficiency in providing adequate and appropriate health care. The resident, who had been in long-term care at the facility, was assessed as severely impaired in daily decision-making skills and dependent on staff for activities of daily living. The care plan included monitoring for complications such as changes in mental status, distension, and fecal impaction, but these were not adequately observed or reported. The clinical records revealed that the nursing staff did not document or monitor the resident's vital signs after a certain date, despite the resident exhibiting signs of distress, such as not eating and refusing to get out of bed. The nurse communicated with the physician about the resident's condition, but the physician's orders were not documented in the clinical record, and no further attempts were made to complete the prescribed work or initiate fluids. The resident's condition worsened, leading to an emergency department visit where severe fecal impaction and other complications were identified. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed that there were lapses in documentation and monitoring of the resident's condition. The staff did not re-approach the resident to complete necessary assessments and treatments, and there was no evidence of documented vital signs or attempts to follow up on the physician's orders. This lack of assessment and monitoring contributed to the resident's deteriorating condition and the subsequent deficiency finding.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission of agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The resident (Resident #1) was sent to the hospital for evaluation and treatment. The family declined surgical intervention and the resident was placed on Hospice services. A medication error was completed for the omission of the medication ordered on . The nurse completed an online Medication Error Prevention course on . How will you identify other residents having potential to be affected by the same deficient practice? An audit was completed on to ensure that no other residents had an unidentified change in condition. No other residents were identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Licensed nursing staff were educated on for the need to complete a Change in Condition Observation in the Electronic Medical Record and to continue monitoring the resident for a minimum of 72 hours which will include vital signs, change in condition progress notes each shift, and notification & updates to the physician and family.