Delayed Response to Change of Condition and Failure to Provide Medically Necessary Equipment
Penalty
Summary
The facility failed to timely address a change in condition for one resident who exhibited symptoms consistent with a urinary tract infection (UTI), including confusion, general weakness, increased urinary frequency, abdominal cramping, and pain during urination. Despite these symptoms being documented by nursing staff, there was a delay in collecting and processing the urine specimen, and antibiotics were not started until four days after symptom onset. The nurse practitioner did not initiate antibiotic treatment based on the resident's symptoms and chose to wait for culture results, even though the resident's condition continued to decline, with documented altered mental status, rapid heart rate, low oxygen saturation, and eventual transfer to the hospital for further evaluation. The Director of Nursing acknowledged that antibiotics could have been started earlier and that the delay should not have occurred. Additionally, the facility failed to ensure timely submission of medically necessary documentation for a power tilt recline wheelchair for another resident with quadriplegia, a traumatic brain injury, and a stage 4 pressure ulcer. The resident was dependent on a power wheelchair for mobility and pressure relief, but the process to obtain a customized wheelchair was delayed for nearly three months due to the facility's lack of follow-up on documentation requests from the equipment vendor. Multiple emails and voicemails from the vendor went unanswered, and the interim rehabilitation director did not submit the required paperwork while covering the department. The resident, who was cognitively intact, became distressed and frustrated by having to coordinate their own care and repeatedly advocate for the necessary equipment. The facility did not have a policy addressing timely assessment, monitoring, and treatment for a change of condition, and failed to provide a requested policy for rehabilitation services. The deficiencies resulted from lapses in communication, lack of timely clinical intervention, and inadequate follow-up on essential documentation, directly impacting the care and well-being of the residents involved.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Resident R905 appeal paperwork and supporting documentation for resident’s specialized wheelchair request has been sent to the vendor by the Director of Rehab on 5/1/2025. Element 2: Director of Nursing / designee reviewed last 7 days of Progress Notes for changes in condition being documented appropriately and timely and with proper notification. Any concerns identified were immediately addressed. Completed on 5/9/2025. Facility has reviewed all current residents that have been evaluated for a specialized wheelchair in the last 60 days to ensure all documentation has been completed timely and if appropriate wheelchair has been provided and care planned. Root Cause: Facility staff did not timely address a resident’s change in condition. Facility failed to submit additional necessary medical documentation timely to order a power wheelchair. Element 3: The Notification of Change policy and the Provision of Quality of Care policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The DON/Designee has re-educated all current nursing staff on Notification of Change policy by 5/14/2025. Any current nursing staff member not re-educated by 5/14/2025 will be re-educated prior to their next scheduled shift. The DON/Designee has re-educated the IDT team and the Rehab team on the Provision of Quality of Care policy by 5/19/2025. Any IDT team member or rehab staff member not re-educated prior to 5/19/2025, will be re-educated prior to their next working shift. The Medical Director has re-educated the Nurse Practitioner on Antibiotic monitoring and timeliness of follow-up. Completed by 5/19/2025. Element 4: The DON/Designee will audit all changes in condition daily, Monday - Friday, to ensure appropriate interventions are placed timely. Audits will continue daily for 4 weeks then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The DON/Designee will audit all specialized wheelchair requests weekly to ensure appropriate documentation is completed and submitted timely. Audits will continue weekly for 4 weeks then monthly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.