Failure to Assess and Respond to Change in Condition Leads to Resident Death
Penalty
Summary
A deficiency occurred when a nurse failed to perform a timely, complete, and accurate assessment of a resident who experienced a change in condition. The resident, who had a complex medical history including sepsis, pneumonia, acute respiratory failure, heart failure, and other chronic conditions, was dependent on staff for activities of daily living and was on oxygen and a feeding tube. On the day of the incident, a CNA reported to the nurse that the resident had an elevated temperature of 101°F and a pulse of 110 at 9:00 a.m. Despite this report and the resident's history of sepsis, the nurse did not conduct a physical or cognitive assessment, nor did she document any such assessment in the medical record between 9:00 a.m. and 5:35 p.m. The nurse delayed any intervention for over four hours, only administering Tylenol at 1:17 p.m. for the increased temperature, without notifying the physician or considering hospital transfer. Interviews confirmed that the nurse acknowledged not performing an assessment or contacting the physician, despite facility policies requiring such actions in response to changes in condition. The Director of Nursing and other staff corroborated that the nurse did not act on the reported vital sign changes and failed to follow established protocols for assessment and escalation. Later that day, the resident was found unresponsive and cold to the touch, with no pulse, and a code blue was called. Despite resuscitation efforts, the resident died. The facility's policies and job descriptions clearly outlined the expectation for timely assessment and physician notification in the event of a change in condition, which were not followed in this case.