Failure to Timely Assess Resident After Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to immediately assess a resident after a reported change in condition. The resident, a male with multiple complex diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac diseases, end-stage renal disease, anemia, hemiplegia, and hemiparesis, was dependent on supplemental oxygen and staff for activities of daily living. On the evening in question, the resident was found to be lethargic and not eating his meals. The CNA reported this to the LPN, but the LPN and an agency LPN did not assess the resident until approximately 30 minutes later, during the shift turnover. Family members also raised concerns and contacted the Director of Nursing, who then instructed the LPN to check on the resident. Despite the facility's protocol requiring immediate attention and completion of a change of condition assessment form when such changes are reported, there was no documentation of an assessment or completion of the required form prior to the resident's transfer to the hospital. This lapse in timely assessment and documentation constituted a failure to provide appropriate treatment and care according to orders and the resident’s needs.