Failure to Assess and Respond to Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, polyneuropathy, hypotension, COPD, and sleep apnea, presented with symptoms including abdominal pain, nausea, distension, and changes in mental status. Despite these symptoms, staff did not document all of the resident's symptoms in the medical record, nor did they complete a thorough and ongoing RN assessment related to the change in condition. There were multiple instances where staff failed to perform a full set of vital signs, abdominal assessments, or pain assessments, even when the resident expressed severe discomfort and abnormal findings were present. The facility's own policy required prompt identification and effective action in response to changes in condition, including in-depth RN assessments and immediate notification of the attending practitioner. However, documentation shows that these steps were not consistently followed. For example, when the resident reported severe abdominal pain and other symptoms, staff administered medications but did not perform or document comprehensive assessments or notify the physician in a timely manner. Critical lab results indicating hyperkalemia and abnormal kidney function were not acted upon with the urgency required, and vital signs that warranted immediate physician notification were not communicated as per standard protocols. Additionally, there was a lack of ongoing monitoring and documentation of the resident's deteriorating condition. Interviews with facility leadership and staff confirmed that expected assessments and documentation were not completed, and that the medical record did not accurately reflect the resident's symptoms or the care provided. The failure to document and respond appropriately to the resident's change in condition, including not notifying the physician of critical changes and not providing continued monitoring, contributed to the resident's continued decline. The resident was eventually transferred to the hospital, where he was found to be pulseless and nonbreathing and subsequently expired due to a critical potassium level.
Removal Plan
- LPN R's employment was terminated.
- Vitals were taken on all residents to ensure no change in condition or need for additional assessment.
- Educational in-services on change in condition were provided for all clinical staff.
- Interviewed all residents and [NAME] of Attorney regarding comfort with cares and facility responsiveness to clinical needs to ensure the facility continues to meet the resident needs to their satisfaction.
- DON B performed chart review for all residents to ensure all changes in condition noted were accompanied by follow-up assessments and proper notification.
- DON B organized a skills fair for nursing to ensure competence in assessments, evaluations, nursing skills, and clinical judgement.
- Management team revamped morning meeting process with additional audits and accountability on 24 hour board.
- Continue audits and education on Stop and Watch program for entire staff. DON B will continue to provide scenarios.