Failure to Monitor and Document Resident's Condition
Penalty
Summary
The facility failed to appropriately assess and monitor a resident experiencing changes in condition, leading to a deficiency in quality of care. The resident, who had been in the facility long-term, was dependent on staff for activities of daily living and had active diagnoses that required careful monitoring. Despite the care plan outlining specific interventions for monitoring complications, the staff did not adequately observe or report the resident's symptoms, such as changes in mental status, abdominal distension, and other signs of obstruction. The clinical records revealed that the nursing staff did not document vital signs or the resident's condition adequately, particularly during a period when the resident exhibited significant changes, such as refusing to eat and remaining in bed. Although the nurse communicated with the physician and received orders for medication, these were not properly documented or followed up in the clinical record. Additionally, there was a lack of documentation regarding the resident's refusal of vital signs and laboratory studies, and no further attempts were made to complete these assessments. The investigation highlighted that the nursing staff failed to assess the resident's condition thoroughly and did not implement the physician's orders effectively. The resident's symptoms, including abdominal distension and fecal impaction, were not adequately addressed, leading to an emergency transfer to the hospital. The facility's documentation was insufficient, and the staff did not re-approach the resident to complete necessary testing and treatment, resulting in a significant oversight in the resident's care.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or 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 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. Nurses have also been educated that they must notify the physician by phone when they initiate a Change in Condition Observation. The Nurses have been re-educated that all physician orders must be entered into the electronic medical record under Orders upon receipt of a new physician's order. How will the corrective action(s) be monitored to ensure the deficient practice will not recur, and what quality assurance program will be put into place? The DON or designee will monitor the Change of Condition Observations initiated by a notification in the Messages tab of the Electronic Medical Record on a daily basis. The DON or designee will schedule a change of condition progress note for every shift for the next 72 hours after the initial Change of Condition Observation has been completed. The DON or designee will audit all Change of Condition Observations twice a week for completion and follow up. Findings will be reported monthly to the QAPI committee for a period of 3 months and or until substantial compliance is achieved.