Failure to Assess, Monitor, and Escalate Care for Resident with Change in Condition
Penalty
Summary
A facility failed to adequately assess and monitor a resident who experienced a significant change in condition, specifically a decline in responsiveness and the inability to take medications. The resident, who had recently undergone joint replacement surgery and was previously alert and mostly independent, began exhibiting symptoms such as persistent vomiting, elevated blood pressure, decreased responsiveness, and generalized weakness. Despite these changes, there was a lack of thorough documentation and monitoring, with gaps in vital sign recordings and insufficient progress notes during critical periods. Nursing staff noted the resident's altered mental status and inability to eat or drink, but did not consistently escalate the situation or ensure timely physician notification as the resident's condition worsened. Multiple staff members, including LPNs and a unit manager, were aware of the resident's deteriorating state. Both day and night shift nurses expressed concern and advocated for the resident to be transferred to a higher level of care, but reported being told by supervisors and management that they could not send the resident to the hospital. The unit manager and other leadership staff did not promptly assess the resident in person despite requests from nursing staff. There was also a failure to notify the physician of the resident's continued decline and omitted medication doses, and the physician was not made aware of the full extent of the resident's unresponsiveness until the following day. The resident remained unresponsive and without adequate monitoring or intervention for approximately 12 hours before being transferred to the hospital, where they were diagnosed with an acute stroke and subsequently died. Interviews with staff revealed confusion and lack of clarity regarding escalation protocols, as well as concerns about administrative interference with clinical decision-making. Documentation was inconsistent, and some assessments were not recorded in the medical record. The deficiency resulted in a significant delay in identifying and treating a critical medical emergency.
Removal Plan
- Resident 802 no longer resides at the facility.
- A one-time audit was completed for nurses notes and change of conditions to ensure appropriate MD notification and follow-up was completed.
- Licensed Nurses were re-educated on the change of condition policy, including appropriate assessment, and timely notification of the physician to prevent serious injury, harm, and or death.
- The facility nurse leadership team did a one-time visual assessment of all current residents to ensure no change in condition is noted and required physician notification is completed.
- The policy on change in condition was reviewed and deemed appropriate.
- DON/designee will review 5 charts weekly to ensure appropriate MD notification and change of conditions have been completed.
- Audits will be forwarded to QAPI committee for review and recommendations.