Failure to Assess and Respond to Change in Condition Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not conducting a thorough assessment, failing to communicate a significant change in condition to the physician, and not ensuring timely and appropriate response from nursing staff during a medical emergency. The resident, who had a history of congestive heart failure and cellulitis, experienced a rapid weight gain of 18.7 pounds in 24 hours, which was not reported to the physician as required by physician orders. Additionally, the resident exhibited symptoms such as slurred speech, swelling, and unresponsiveness, which were observed by multiple nursing assistants and reported to the assigned nurse, but no timely or adequate action was taken. The assigned nurse did not assess the resident promptly despite repeated notifications from nursing assistants about the resident's deteriorating condition. The nurse also failed to document or notify the physician of the resident's significant weight gain, changes in condition, or the need to increase oxygen therapy. When the resident became unresponsive, nursing assistants initiated CPR and called emergency services, but the nurse did not provide direction or assist with resuscitation efforts. There was also a lack of documentation regarding physician notification following the resident's unexpected death. The facility's investigation into the incident was incomplete, lacking staff statements and failing to report the death to the state hotline or coroner's office. Interviews with staff revealed concerns about the nurse's lack of urgency and inadequate response, as well as a lack of communication and follow-through by facility leadership. The failure to assess, communicate, and respond appropriately to the resident's change in condition resulted in harm to the resident and placed all residents at risk of unmet care needs and potential neglect.