Failure to Monitor Changes, Assess Wounds, and Provide Specialized Services
Penalty
Summary
The facility failed to thoroughly evaluate and monitor significant changes in a resident's respiratory condition and increased sedation from medications, resulting in actual harm. One resident with multiple diagnoses, including a recent fracture, heart disease, and chronic pain, exhibited signs of respiratory distress, confusion, and lethargy over a two-day period. Despite staff observations of abnormal skin color, slow responses, and complaints of pain and shortness of breath, there was a lack of timely and thorough assessment, delayed completion of ordered diagnostic tests, and inadequate monitoring of medication side effects. The resident ultimately experienced an opioid overdose and aspiration pneumonia, requiring emergency hospital intervention. Another resident with end-stage renal disease and a history of pressure injuries experienced a worsening coccyx wound that was not promptly assessed or reported to the provider. Nursing staff documented the wound's deterioration but failed to complete a full assessment, obtain measurements, or notify the provider in a timely manner. Communication breakdowns among staff and the interdisciplinary team led to a four-day delay in addressing the wound, during which the resident experienced severe pain. Staff interviews revealed confusion about wound assessment responsibilities and a lack of training in staging pressure injuries. Additionally, the facility did not follow through with specialized services for two residents. One resident with Alzheimer's disease and malnutrition was observed repeatedly leaning to one side in their wheelchair without the prescribed positioning wedge, as staff were unaware of the care plan and equipment needs due to poor communication between therapy and nursing. Another resident with a history of liver transplantation and chronic hepatitis did not receive timely referrals to a gastroenterologist or hepatologist as ordered, with staff citing workload and oversight as reasons for the delay. These failures placed residents at risk of not receiving necessary care and services to prevent decline in health and mobility.