Failure to Assess, Monitor, and Treat Changes in Resident Condition
Penalty
Summary
The facility failed to assess, monitor, and treat changes in respiratory, skin, and bowel patterns for four residents, resulting in significant declines in their health status. For one resident with Parkinson's disease, dementia, and dysphagia, there was a documented decline in transfer ability, eating, and alertness, which ultimately led to delayed response and hospitalization for pneumonia. Despite clear signs of respiratory distress, including increased lethargy, abnormal lung sounds, and suspected aspiration, there was no timely follow-up testing such as a chest x-ray, and comprehensive nursing assessments were not completed after a change in condition was identified. Documentation gaps and delays in physician notification were also noted, with staff failing to initiate pertinent charting or monitoring for infection after the resident's condition changed. Another resident with diabetes and dementia had a chronic, non-healing wound on the nose that was not assessed, monitored, or treated according to facility protocols. The wound, which was present for at least six months and exhibited characteristics that could indicate skin cancer or infection, was not documented in the electronic medical record, and there was no evidence of physician notification or wound evaluation. Staff interviews revealed a lack of awareness and follow-up regarding the wound, and the resident was only placed on a provider assessment list after the issue was raised during the survey. Additionally, the facility failed to appropriately monitor and treat constipation for three residents, despite physician orders and care plan interventions. Documentation showed prolonged periods without bowel movements, and as-needed medications for constipation were not administered according to orders. The facility lacked a policy or protocol for constipation management, and alerts in the electronic medical record were not consistently acted upon. Interviews with the DON confirmed that staff did not follow standard practices for monitoring bowel elimination and initiating interventions after three days without a bowel movement.