Failure to Timely Respond to Resident's Change in Condition Resulting in Hospitalization
Penalty
Summary
Facility staff failed to protect a resident from neglect by not responding in a timely manner to a significant change in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including dysarthria following cerebral infarction, heart failure, and atrial fibrillation, was admitted for post-acute care. On the morning following admission, documentation indicated the resident was alert and responsive, but by the next day, staff observed that the resident was not opening her eyes, was not eating, and was refusing medications. Despite these changes, there was a lack of prompt and thorough assessment and escalation by nursing staff. Throughout the morning and early afternoon, the resident remained unresponsive to verbal stimuli, did not eat breakfast or lunch, and did not take her scheduled medications. The primary CNA reported these changes to the nurse, but the nurse assumed the resident was tired and did not immediately escalate the situation. The PA was not notified of the resident's condition until the afternoon, and the unit manager was unaware of the resident's status until late in the day. When the resident was finally assessed by multiple nurses, she was found to be nonverbal, with abnormal pupil response and froth in her mouth, prompting an emergency transfer to the hospital. Upon arrival at the hospital, the resident was admitted to the ICU with a diagnosis of cerebrovascular accident (CVA) and had a Glasgow Coma Scale score of 8, indicating a coma. The facility's failure to recognize and respond to the resident's change in condition in a timely manner resulted in a delay in necessary medical intervention and transfer to a higher level of care.