Failure to Respond to Resident's Change in Condition Resulting in Serious Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who had a history of right leg above the knee amputation, left arm paralysis following stroke, peripheral vascular disease, dysphagia, respiratory failure, and diabetes, reported shortness of breath to certified nurse aides (CNAs) in the early morning. The CNAs observed the resident's symptoms and promptly informed an LPN of the significant change in condition. Despite being notified multiple times by the CNAs about the resident's shortness of breath and complaints of not feeling well, the LPN failed to collect comprehensive information regarding the resident's condition. The LPN did not perform a full assessment, did not obtain a complete set of vital signs, and did not notify a registered nurse (RN) or the physician about the resident's significant change in condition. The LPN only measured the resident's oxygen saturation, which was 92%, and did not further investigate or escalate the situation as required by facility policy and professional standards. As a result of these inactions, the resident was later found unresponsive and not breathing, and was pronounced deceased. Documentation and interviews confirmed that no RN assessment or complete evaluation was conducted after the resident began experiencing a change in condition. The CNAs continued to report the resident's symptoms to the LPN, but did not escalate the concern to another nurse or the DON at the time. The failure to promptly identify and appropriately intervene when the resident experienced a significant change in condition resulted in a situation of serious harm.