Failure to Timely Assess Change of Condition After Therapy Notification
Penalty
Summary
Nursing and therapy staff identified a change in condition for a resident with multiple complex diagnoses, including a recent hip fracture, pneumonia, COPD, malnutrition, and schizoaffective disorder. On the day in question, both physical and occupational therapy staff documented that the resident was lethargic and notified nursing staff of this change. Despite these notifications, there was no documented nursing assessment or vital signs recorded by nursing staff after the initial reports of lethargy until several hours later. The clinical record showed that the resident's oxygen saturation dropped from 95% in the morning to 87% in the evening, at which point nursing staff finally documented an assessment noting lethargy, shortness of breath, and low oxygen saturation. The Director of Nursing confirmed that no change of condition assessment was documented after therapy staff notifications and stated that nurses are expected to assess residents after such notifications. Additionally, the facility was unable to provide a policy and procedure for assessment after a change of condition when requested by surveyors.