Failure to Assess, Notify Physician, and Ensure CPR-Certified Staff Leads to Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide a thorough assessment and timely recognition of a significant change in condition for a resident with a history of congestive heart failure and cellulitis. The resident experienced a rapid weight gain of 18.7 pounds in 24 hours, swelling in the left arm, slurred speech, difficulty breathing, and changes in mentation throughout the day. Despite these symptoms, there was no documentation that the physician was notified of the significant weight gain or the resident's deteriorating condition, as required by the care plan and physician orders. Multiple nursing assistants observed and reported the resident's changes, including incoherence, slurred speech, and abnormal appearance, to the assigned RN. However, the RN did not assess the resident in a timely manner, did not notify the physician, and did not document appropriate interventions. The last recorded vital signs were taken in the morning, and the resident's condition continued to decline throughout the day. When the resident became unresponsive and pulseless, there was a delay in initiating emergency interventions, and the RN did not perform CPR, leaving it to the nursing assistants. Further review revealed that the RN and other staff members lacked current CPR certification, contrary to facility policy requiring all RNs and LPNs to maintain active certification. The facility's failure to ensure adequate assessment, timely physician notification, and the presence of properly certified staff contributed to the resident's unexpected death. The resident was a full code and was not expected to pass away, with plans to return home after rehabilitation.
Removal Plan
- Terminated the staff that failed to assess, treat and notify the physician of Resident 1 regarding their significant change in condition.
- Audited the records of all residents for unidentified changes in condition.
- Educated staff on what to do when a resident has a change in condition.
- Audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications.