Failure to Accurately Assess and Document Neurological and Respiratory Status
Penalty
Summary
The facility failed to ensure accurate assessments and documentation for two residents with significant medical conditions. For one resident with a history of 6th abducent nerve palsy, 3rd oculomotor nerve palsy, and blepharoconjunctivitis, observations revealed unequal pupils—one dilated and nonreactive, the other normal—yet skilled charting repeatedly documented the pupils as equal, round, and reactive to light over several months. The resident's care plan addressed issues such as impaired vision and droopy eyelids but did not include interventions or monitoring for the known unequal pupils, despite this being a longstanding condition. Staff interviews confirmed a lack of awareness and proper documentation regarding the resident's pupil irregularities. For another resident with acute respiratory failure, pneumonitis, and dysphagia, physician orders required shift-by-shift documentation of breath sounds and related respiratory assessments following episodes of pneumonia and chest tube removal. However, multiple shifts lacked documentation of breath sounds as ordered, with specific dates noted where assessments were not completed. The DON acknowledged that the required assessments were missed. Facility policies required comprehensive neurological and respiratory assessments, but these were not consistently followed for the residents reviewed.