Failure to Assess and Notify Provider of Persistent Tachycardia Leading to Hospitalization
Penalty
Summary
The facility failed to consistently assess and adequately follow up on a change in condition for a resident who was dependent on staff, non-communicative, and required mechanical ventilator support. The resident had a history of lung and skin infections with multiple drug-resistant organisms and a prior episode of sepsis. According to the care plan, the resident's respiratory status and vital signs were to be monitored every six hours, with staff responsible for identifying and responding to abnormalities. From early to mid-December, the resident's heart rate was documented as elevated above 100 bpm on multiple occasions over several days. Despite these abnormal findings, there was no documented nursing assessment or timely notification to the medical provider regarding the persistent tachycardia. The respiratory therapist notified nursing staff of the elevated heart rate, but subsequent nursing assessments and provider notifications were either not performed or not documented. Blood pressure readings were also missing for a significant period during this time. It was not until the resident experienced a sudden increase in respiratory needs that immediate action was taken, resulting in hospital transfer and a diagnosis of abdominal sepsis and acute on chronic respiratory failure. Interviews with staff confirmed that the expected protocol of reassessment, documentation, and provider notification was not followed in response to the resident's change in condition, and that the provider was not fully informed of the extent and duration of the elevated heart rate.