Failure to Complete Comprehensive Assessments and Notify Provider of Change in Condition
Penalty
Summary
The facility failed to ensure comprehensive nursing assessments were completed and did not identify or notify the provider of a change in condition for one resident with significant chronic respiratory conditions. The resident, a male with progressive multifocal leukoencephalopathy and a history of multiple hospitalizations for sepsis, aspiration pneumonia, and acute respiratory distress, required frequent monitoring and interventions, including suctioning and temperature management. The resident's care plan specifically instructed staff to observe for and report signs and symptoms of acute respiratory insufficiency and infection, and to document and communicate abnormal findings to the physician. Despite these instructions, after the resident's return from a recent hospitalization, there was no documentation of a provider assessment or a comprehensive respiratory assessment by licensed nurses. The last full set of vital signs was recorded on one date, with only sporadic temperature checks thereafter, even though the resident experienced a fever and was administered Tylenol. The provider was notified of the fever and instructed staff to manage it in-house, with the expectation of continued monitoring, but there was no evidence of ongoing temperature monitoring or further sepsis screening evaluations until the resident was found unresponsive and subsequently pronounced deceased. Interviews confirmed that the facility's nursing home administrator expected nurses to assess temperatures when administering Tylenol for fever and to complete respiratory assessments for residents returning from hospitalization due to respiratory illness. However, these assessments were not completed, and there was no provider assessment following the resident's readmission, despite the resident's complex medical history and recent acute changes in condition.