Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to provide timely assessment and care for a resident who experienced a significant change in condition. The resident, who had a history of multiple sclerosis, paraplegia, and was cognitively intact, began experiencing right arm and hand weakness, numbness, and loss of motor skills. These symptoms were first reported to nursing assistants in the morning and throughout the day, but no licensed nurse assessed the resident until the following morning. Despite multiple reports from nursing assistants and a family member, the licensed practical nurses did not assess the resident or escalate the concern appropriately. The resident was eventually assessed by the charge nurse after further decline and was sent to the hospital, where a stroke was diagnosed. Interviews with staff and review of documentation revealed that nursing assistants reported the resident's symptoms to several LPNs, but these concerns were not acted upon in a timely manner. The LPNs either did not recognize the urgency of the symptoms or believed that assessment for a stroke was outside their scope of practice. As a result, the resident did not receive a nursing assessment or medical evaluation for over 18 hours after the initial onset of symptoms. The facility's policy required staff to assess and report changes in condition, but this was not followed in this case. A second resident also experienced a delay in assessment and care after reporting leg pain and swelling. The resident requested to go to the emergency department multiple times throughout the day, but staff did not act on these requests until late in the evening. Documentation and interviews indicated that the resident's concerns were not promptly communicated to the nurse practitioner, and there was a lack of timely assessment and documentation by the nursing staff. Both cases demonstrate failures in timely assessment and response to changes in condition, as well as inadequate communication among staff.