Failure to Notify Physician and Family or Initiate Interventions After Resident Change in Condition
Penalty
Summary
A deficiency occurred when a resident with chronic atrial fibrillation, repeated falls, and dementia experienced a significant change in condition during the early morning hours. The resident, who had a DNR order but was not on hospice, was found by a CNA to have not voided during the shift and was exhibiting agonal breathing, cold skin, and fixed pupils. The CNA immediately notified the nurse (LVN A), who assessed the resident and noted low vital signs and signs of active dying. Despite these findings, LVN A did not notify the physician, nurse practitioner, or the resident's family, nor did she initiate any interventions or further assessments beyond monitoring the resident at 15-minute intervals. LVN A stated she believed that because the resident was a DNR and the family had previously requested not to be called during the night unless it was an emergency, no further action was required. She also mistakenly believed the resident was on hospice. The oncoming nurse (LVN C), upon receiving report and assessing the resident, immediately recognized the severity of the situation, called EMS, notified the NP, family, and DON, and arranged for the resident to be transported to the hospital, where the resident was later pronounced deceased due to cardiopulmonary arrest. Interviews with facility leadership, including the DON and Administrator, confirmed that LVN A failed to follow professional standards of practice by not notifying the appropriate medical providers or the family and by not initiating timely interventions in response to the resident's change in condition. The facility's policy required prompt notification of the physician and representative in the event of a significant change, which was not followed in this case. The DON and Administrator both described the nurse's actions as neglectful and not in accordance with facility protocols.