Failure to Assess and Respond to Change in Condition Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to assess and monitor a resident who exhibited a change in condition, resulting in a lack of timely emergency medical intervention. The resident, who had a history of significant cardiac issues including myocardial infarction, hypertension, and episodes of unresponsiveness, was reported by both their roommate and two CNAs to be in distress around 5 a.m. The CNAs and the roommate observed the resident with their head tilted back, mouth open, and white foam coming from the mouth, and repeatedly notified the on-duty RN. Despite these reports, the RN did not perform an assessment, obtain vital signs, or attempt to arouse the resident, instead stating the resident was just sleeping and snoring, which was not unusual for them. The CNAs continued to express concern to the RN, but the RN did not return to the room or further evaluate the resident. The roommate also attempted to alert the RN multiple times and expressed regret for not calling 911 themselves. The RN later confirmed to the Director of Nursing that they were informed by staff and the roommate about the resident's condition but did not act, citing other tasks. The resident was ultimately found unresponsive by the day shift nurse, who immediately began emergency measures and called EMS, but the resident was pronounced deceased shortly thereafter. The resident's medical record indicated prior episodes of acute distress, including previous hospitalizations for heart attack and unresponsiveness, and a care plan that required monitoring for chest pain, shortness of breath, and changes in condition. The facility's policy required staff to recognize and manage changes in condition, but the RN failed to follow these protocols, resulting in a lack of timely assessment and intervention for the resident.
Plan Of Correction
Element 1: Resident 602 no longer resides at the facility. Element 2: Current residents are at risk for requiring emergency care or experiencing adverse events if Change of Condition is not recognized and assessed in a timely manner. Education was completed prior to survey including review for other residents to determine any ongoing needs secondary to Change in Condition. A follow-up 1x audit was completed for the past 3 days to determine any residents experiencing a Change of Condition that required further assessment or monitoring. Concerns were addressed as needed. Element 3: Current staff were re-educated on Recognizing Change of Condition and steps to take regarding needed assessments and monitoring. Licensed nurses were re-educated on needed assessments, documentation, and notification when a Change of Condition is recognized. Staff who do not receive the education by the date of compliance will receive education on the day of work. Non-compliance with the education on the day of work. Non-compliance with the education will result in 1:1 education or written discipline per policy. System Change: Increase Monitoring. Element 4: DON/designee will complete audits of 24-hour report for Change of Condition including any needed Assessment and Documentation daily M-F x 4 weeks then weekly x 4 weeks and ongoing per QA committee recommendations. Results of audits will be reported to QAPI monthly x 3 months and PRN. DON is responsible for ongoing compliance.