Failure to Provide Timely Assessment, Monitoring, and Physician Notification Following Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute respiratory failure, severe sepsis, pneumonia due to MRSA, UTI, diabetes, and pleural effusion, did not receive care and treatment according to physician orders and facility protocols. The resident was noted to have an elevated temperature and yellow emesis, prompting a physician order for transfer to a hospital, which was later canceled at the family's request. The physician then ordered vital sign monitoring every four hours, initiation of Augmentin, and a urinalysis with culture. However, vital signs were only recorded twice after the order and not every four hours as required, and there was no documentation of vital signs after the early afternoon. The resident's medication administration record did not indicate that Augmentin was administered, and staff interviews revealed confusion and lack of recall regarding the medication's administration and the monitoring of vital signs. Further deficiencies were identified when a nurse failed to notify the physician or hand over to another licensed nurse that the resident had not passed urine and that urine could not be collected for the ordered urinalysis. The nurse assumed someone else would report the lack of urine output and only endorsed the issue to the next shift. Additionally, when the resident developed difficulty breathing on two occasions in the evening, there was no evidence that a registered nurse or the assistant director of nursing assessed the resident, and 911 was not called immediately. Instead, the respiratory therapist was called, and oxygen was administered, but the resident's condition deteriorated further. Ultimately, the resident was found not breathing well later that night, and paramedics were called. Upon arrival, the paramedics found the resident in cardiac arrest and were unable to resuscitate, pronouncing the resident dead at the facility. The facility's own policies required prompt assessment, monitoring, and reporting of changes in condition, as well as timely administration of medications and vital sign monitoring, all of which were not followed in this case.