Failure to Monitor and Follow Physician Orders Leads to Resident Decline
Penalty
Summary
The facility failed to assess, monitor, and follow physician orders for a resident with multiple diagnoses, including hypotension, COPD, and acute respiratory failure with hypoxia. The resident was cognitively intact and had recently been seen by a nurse practitioner for acute hypoxia and shortness of breath, resulting in new orders for PRN Midodrine for hypotension and Albuterol for shortness of breath. Despite these orders, documentation showed that vital signs were not consistently monitored or recorded as required, and the resident did not receive the ordered Albuterol when experiencing shortness of breath. On the day of the incident, the resident's blood pressure was critically low, and a dose of Midodrine was administered. However, after this administration, there was a lack of ongoing monitoring, as no additional vital signs were documented after a certain point, and no further doses of Midodrine were considered despite continued hypotension. Staff interviews confirmed that the resident was observed to be declining, lethargic, and nonverbal, deviating from his baseline condition, but these changes were not adequately addressed through timely assessment or intervention. The resident ultimately became unresponsive and went into cardiac arrest, requiring CPR and emergency transfer to the hospital. Hospital records indicated the resident suffered from septic shock, lactic acidosis, and was placed on comfort care. The failure to follow physician orders for monitoring and medication administration, as well as the lack of timely assessment and response to a significant change in condition, directly contributed to the poor outcome.