Failure to Provide Timely Medical Intervention for Acute Change in Condition
Penalty
Summary
The facility failed to provide timely medical intervention for a resident who experienced an acute change in condition, resulting in actual harm. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and previous cerebral infarction with right-sided hemiplegia and hemiparesis, reported numbness and weakness on the right side of the body and requested to be sent to the hospital. Despite these symptoms, which began several days prior and included a fall due to right leg weakness, the resident was not transferred to the hospital until over three hours after the initial complaint. During this time, the resident's symptoms were not thoroughly evaluated, and there was no evidence that the physician was promptly notified or that a physician order for hospital transfer was obtained. Documentation and interviews revealed that nursing staff did not conduct a comprehensive assessment of the resident's neurological status following the complaint of numbness and weakness. The resident's vital signs were taken and found to be within normal limits, but the underlying neurological symptoms were not adequately addressed. The decision to use non-emergency transportation further delayed the resident's transfer, and there was no documentation of timely physician notification or input regarding the resident's acute change in condition. Additionally, the resident's responsible party was not notified of the transfer to the hospital as required by facility policy. Upon arrival at the hospital, the resident was diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. The hospital determined that the resident was outside the window for significant intervention, and a stroke alert was not called. Following hospitalization, the resident's mobility declined, necessitating the use of a wheelchair. The facility's failure to promptly recognize and respond to the resident's acute neurological symptoms, notify the physician, and arrange for immediate transfer resulted in a delay of care and actual harm to the resident.