Failure to Identify and Assess Significant Change in Resident Condition
Penalty
Summary
The facility failed to timely identify and assess a significant change in condition for a resident who was admitted with a history of falls and was initially cognitively intact, independent in upper body tasks, and without behavioral symptoms. After an unwitnessed fall resulting in a left arm fracture, the resident was supposed to be monitored and placed on alert charting for 14 days to determine if a significant change in condition had occurred. However, there was no documentation indicating that alert charting was implemented or that the resident refused care. Staff interviews revealed that the resident became resistant to care, exhibited verbal aggression, and began wandering, which were changes from the resident's baseline status at admission. Further observations and staff interviews indicated a decline in the resident's functional and cognitive status, including moderate impairment in decision-making, new behavioral symptoms such as suicidal ideation and threats, and increased care refusals. Despite these changes, no significant change of condition assessment was completed, and there was a lack of progress notes documenting the resident's altered status. Staff involved were unsure of the criteria for completing a significant change assessment, and facility leadership acknowledged that such an assessment should have been performed.