Failure to Identify and Respond to Change in Condition Resulting in Delayed Treatment
Penalty
Summary
A deficiency occurred when staff failed to identify and respond to a resident's change in condition, resulting in a delay in treatment. The resident, an elderly male with Parkinson's disease, tremor, and vascular dementia, required assistance with oral care and dentures. On the morning of 5/11/2025, a CNA noticed the resident did not have his dentures but did not report this to anyone, assuming they were misplaced. Other CNAs who assisted the resident over the weekend either did not notice the missing dentures or did not check the care report, and one reported hearing gurgling sounds but attributed it to oral care. The resident's family also reported gurgling noises, which prompted a nurse to assess the resident and order a non-urgent chest x-ray, but no immediate action was taken. Nursing staff noted diminished lung sounds and audible congestion, but the x-ray was not performed until the following day. The resident was found to be lethargic and had further diminished lung sounds, leading to a decision to transfer him to the hospital for evaluation. Paramedics documented difficulty breathing, decreased oxygen saturation, and a Glasgow Coma Scale of 10, indicating moderate impairment. Hospital evaluation revealed a dental appliance lodged in the hypopharynx, which required removal under anesthesia. The resident was also diagnosed with pneumonia and started on antibiotics. The facility's care plan indicated that the resident required staff assistance with oral care and had both upper and lower dentures. Despite this, staff failed to report the missing denture and did not adequately assess or escalate the resident's change in condition, resulting in a delay in identifying the foreign body aspiration. This delay contributed to the resident's hospitalization and the need for surgical intervention.