Failure to Report and Address Abnormal Vital Signs and Changes in Condition
Penalty
Summary
The facility failed to identify and report ongoing abnormal vital signs and did not complete required respiratory assessments for two residents. For one resident, there were multiple instances where abnormal vital signs, such as low blood pressure and elevated heart rate, were documented without physician notification. This resident also exhibited shortness of breath on exertion for several days, but the care plan did not address respiratory or cardiovascular concerns, and there was no evidence of follow-up or reporting to the physician. The resident experienced a significant change in condition, including loss of consciousness and irregular breathing, which ultimately led to a hospital transfer. Documentation was incomplete regarding the incident leading to the transfer and the vital signs at the time of a prior fall were not recorded. For the second resident, who had a history of Parkinson's Disease, coronary heart disease, and hypertension, there were repeated episodes of bradycardia (low heart rate) and hypotension. The medication administration record included parameters to hold antihypertensive medication for low blood pressure or heart rate, and the medication was held on several occasions. However, documentation frequently lacked evidence of timely physician notification regarding the persistent abnormal vital signs. The resident experienced multiple falls, episodes of unresponsiveness, and eventually a respiratory arrest that resulted in hospital transfer and subsequent death. Staff interviews confirmed that abnormal vital signs were not always communicated to the provider as required by facility policy. Facility policy required that all significant changes in condition, including abnormal vital signs, be reported to the physician prior to the end of the shift and that all actions and communications be documented in the nursing progress notes. Despite this, the records showed gaps in both notification and documentation for abnormal findings and changes in condition for both residents. The Director of Nursing and other staff confirmed expectations for reporting and documentation, but the review found these were not consistently followed.