Failure to Perform Comprehensive Assessment During Change of Condition
Penalty
Summary
The facility failed to conduct thorough and timely assessments for a resident who experienced a change of condition related to abdominal pain, distension, and respiratory distress. Multiple nursing staff, including RNs and LVNs, did not fully assess the resident's abdomen for distension, firmness, rebound, guarding, bowel sounds, or pain at various points when the resident reported symptoms of constipation, abdominal discomfort, and shortness of breath. Documentation and interviews revealed that assessments were incomplete or not performed, and that pain levels were not consistently evaluated or communicated to the physician. The resident, who had a history of COPD, chronic respiratory failure, and muscle wasting, was admitted and readmitted with these diagnoses. The care plan indicated the resident was at risk for discomfort and shortness of breath due to COPD and required oxygen therapy. Despite complaints of not having a bowel movement for two days, abdominal pain, and bloating, the nursing staff did not perform comprehensive gastrointestinal assessments as required by facility policy. Additionally, when the resident requested an increase in oxygen due to difficulty breathing, staff increased the oxygen flow without first assessing the resident's oxygen saturation. Communication lapses were also evident, as staff did not consistently relay full assessment findings to the physician, which was necessary for determining appropriate interventions. The resident continued to experience pain and abdominal symptoms, and ultimately was found unresponsive and pronounced deceased after resuscitative efforts. The facility's policy required thorough assessment and physician notification for abnormalities, but these steps were not followed, resulting in the deficiency.