Failure to Monitor Residents After Change in Condition
Penalty
Summary
The facility failed to monitor and reassess two residents after a change in their medical condition. For one resident with a history of left femur fracture and hypertension, the resident experienced vomiting, sweating, hypotension, and tachycardia. The physician was notified and recommended continued monitoring, and 911 was called, but the resident initially refused transfer. The resident had another episode of vomiting several hours later and was then transferred to a hospital. During the six-hour period between the initial episode and the transfer, there was no reassessment of vital signs documented. For another resident with diagnoses of congestive heart failure and end stage renal disease on dialysis, the resident was found to have low blood pressure. The physician was notified and recommended blood pressure checks every thirty minutes for three times. However, there was no documentation of vital sign reassessment for approximately six hours until 911 was called and the resident was transferred. The Director of Nursing confirmed that vital signs should have been reassessed every 15-30 minutes after a change in condition, even without a physician order.