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F0600
J

Failure to Provide Timely Assessment and Physician Notification Following Change in Condition

Milford, Ohio Survey Completed on 04-09-2025

Penalty

Fine: $53,370
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with multiple complex medical conditions, including Type I diabetes mellitus, end-stage renal disease, and a tracheostomy, was not provided with appropriate and timely assessment, treatment, and physician notification following a significant change in condition. The resident had a history of non-compliance with insulin administration and repeatedly refused prescribed doses, including a critical dose ordered after a blood glucose reading of 583 mg/dL. Despite being educated on the risks of refusal, the resident continued to decline insulin, and the nurse did not notify the physician or nurse practitioner of this refusal, nor were additional blood glucose checks performed or documented. Later, the resident was found on the floor, unresponsive to questions but able to move extremities, and with noticeable facial swelling. No neurological assessment was completed, and again, there was no notification to the physician or nurse practitioner regarding the resident's change in condition. The resident remained in this state without further assessment or intervention until the following morning, when she was found unresponsive with bluish skin tone, abdominal breathing, and significant head edema. At this point, emergency services were called, and the resident was transported to the hospital. Upon hospital admission, the resident was found to have a blood glucose level greater than 784 mg/dL, was diagnosed with acute encephalopathy, multiple metabolic/infectious abnormalities, and acute metabolic acidosis, and ultimately died. Throughout this period, there was a lack of timely assessments, failure to follow physician notification protocols, and inadequate documentation, all of which contributed to the resident's serious deterioration and death. Interviews with staff and review of records confirmed that required neurological checks and physician notifications were not performed as per facility policy.

Removal Plan

  • Resident was sent to the ED with notification made to the physician.
  • Administrator and Minimum Data Set (MDS) Nurse reviewed the 24-hour report and self-identified a concern with resident's refusal of an order for insulin and failure to notify the physician/nurse practitioner during clinical meeting.
  • Administrator and RDCO obtained statements and conducted interviews with LPN Unit Manager, Medication Technician, LPNs, Respiratory Therapists, Certified Nurse Aides, and previous DON.
  • RDCO was notified by Administrator of the situation that involved the resident and arrived at the facility to assist with the investigation.
  • RN/Staff Development Coordinator (SDC) assessed all residents who had a recent fall and completed a neurological check.
  • LPNs, RDCO, and LPN Unit Manager assessed all residents for a change in condition.
  • Administrator suspended previous DON pending investigation for failure to notify Nurse Practitioner of resident's refusal to be administered insulin as ordered and subsequent change in condition. Previous DON was terminated from employment.
  • RN/SDC provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record. All staff were educated.
  • RDCO and Administrator notified facility Medical Director of the incident and reviewed the policy and procedure for change in condition/notification of change.
  • A Quality Assurance and Performance Improvement (QAPI) meeting was held with Administrator, RDCO, and Medical Director. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed.
  • RN, LPNs completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed.
  • RDCO reviewed all resident blood sugars to ensure notification of variances was made to the physician.
  • RDCO/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs.
  • RDCO/designee conducted a clinical meeting to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue.
  • RDCO/designee monitored the results of the clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued with QAPI meetings and then as needed.
  • Two additional resident medical records were reviewed for abuse and neglect with no concerns identified.
  • All staff were interviewed to verify receipt and understanding of education regarding a resident change in condition or mental status change from the resident's baseline.
See complete original report
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