Failure to Identify and Respond to Change in Condition, Medication Administration, and Documentation Deficiencies
Penalty
Summary
Facility staff failed to ensure timely identification, assessment, and reporting of a resident's change in condition, resulting in multiple hospitalizations. The resident, who had a history of fracture, repeated falls, severe malnutrition, dysphagia, and weight loss, exhibited ongoing symptoms such as poor appetite, gagging, and dry heaving. Despite family concerns and reports of aspiration and emesis, staff did not perform or document comprehensive assessments or obtain vital signs prior to significant events, including hospital transfers. Documentation revealed that staff relied on secondhand information rather than direct assessment, and there was no evidence of timely physician notification or accurate evaluation of the resident's status during these episodes. The facility also failed to follow professional nursing standards for medication administration and monitoring. Blood pressure readings were not consistently obtained before administering antihypertensive medications, and there were instances where medications were held or given without appropriate clinical justification or documentation. Additionally, the facility did not implement or document physician orders for supplemental oxygen and intravenous therapy as required. Oxygen was administered without a physician order, and there was no documentation explaining the rationale, timing, or physician notification regarding changes in oxygen delivery or the resident's elevated heart rate. Nursing skilled notes were incomplete or inaccurate, with missing assessments on key dates and discrepancies between documented care and the resident's actual needs. Orders for IV fluids were not carried out, and abnormal vital signs, such as critically low blood pressure, were not reported to the physician. The lack of timely transfer to a higher level of care, incomplete documentation, and failure to follow facility policies contributed to the resident's repeated hospitalizations and ultimately, the resident's death. Interviews with facility leadership confirmed gaps in assessment, documentation, and adherence to policy.
Plan Of Correction
F684 - Quality of Care It is the practice of the facility to ensure that quality care is provided following the fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Element 1: Resident R402 no longer resides in the facility. Element 2: Residents residing in the facility who have a change in condition have the potential to be affected by the cited practice. The facility has completed audits and reviews of current residents pertaining to any of the cited practices listed below. An audit was conducted to ensure that residents with a change of condition have appropriate evaluation, monitoring, documentation, and physician notification. An audit was conducted on residents who have blood pressure medications to ensure their vital signs were obtained and orders followed as written. A full house sweep was conducted of resident rooms for oxygen and IV equipment and was reconciled with resident active orders for oxygen and IV medications. An audit of residents recently transferred to acute care since the date of survey exit (4/10/2025) was conducted to ensure that acute care transfer was completed in a timely manner in accordance with the residents' needs. If any of the above noted areas were found to be out of compliance, they were corrected immediately with all necessary parties notified. Element 3: A QAPI meeting was held by the interdisciplinary team who reviewed the change of condition policy, medication pass policy, physician orders policy, and the resident transfer policy, to which all were deemed appropriate for use. Facility nurses will be reeducated on the policies with a focus on changes in condition and completion of documentation of the change in condition. Element 4: The DON/Designee will audit for resident changes of condition twice a week for 4 weeks, then monthly for 3 months. Audits will include but are not limited to timely identification, accurate assessment, monitoring, and documentation of the resident's change in condition, documentation and implementation of physician orders, and timely transfers to a higher level of care when necessary. Residents will be discussed within the morning IDT meetings Monday-Friday. The results of the audits will be reviewed during the monthly QAPI meeting. Any areas found to be out of compliance will be corrected immediately with physician and family notifications completed as appropriate. Element 5: The director of nursing is responsible for ultimate compliance. Compliance date of May 6, 2025.