Failure to Respond to Resident's Request and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, who was receiving dialysis and had a history of low blood pressure, was found to have a blood pressure of 80/42, complained of generalized pain, and requested to be sent to the hospital. Despite the resident's request and abnormal vital signs, the nursing staff did not immediately intervene or send the resident to the hospital. Instead, the resident was sent to dialysis as scheduled after the charge nurse consulted with the former ADON, who advised that the resident usually had low blood pressure and should proceed to dialysis. The nurse documented the resident's request and low blood pressure but did not notify the nurse practitioner or physician for further orders regarding the hospital transfer at that time. At the dialysis center, the resident continued to experience hypotension and generalized weakness, and again requested to be sent to the hospital. The dialysis nurse contacted the nephrologist, who ordered intravenous fluids to stabilize the resident's blood pressure. When the resident's condition did not improve, the dialysis center arranged for the resident to be sent to the hospital. Interviews with facility staff revealed that the nurse practitioner was not notified of the resident's condition prior to dialysis, and stated that, had she been informed, she would have ordered the resident to be sent to the hospital via EMS due to the unsustainable blood pressure. Facility policy required prompt notification of the physician and resident representative in the event of significant changes in a resident's condition, including abnormal vital signs and requests to go to the hospital. However, the staff failed to follow these protocols, resulting in a delay in medical intervention for the resident. The deficiency was identified as Immediate Jeopardy due to the failure to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's expressed preferences.