Failure to Document, Assess, and Notify Physician for Changes in Resident Condition
Penalty
Summary
Three residents experienced deficiencies in care and services due to failures in documentation, assessment, and timely physician notification. One resident, with a history of diabetes mellitus and hypertension, had a physician order for laboratory tests to be drawn every three months. Despite three consecutive unsuccessful blood draws, there was no documentation of a change in condition (COC) or physician notification, as confirmed by both the LVN and the Director of Nursing. The lack of documentation meant that staff were not formally alerted to the change in the resident's status or the need for monitoring. Another resident, with diagnoses including diabetes mellitus, hemiplegia, anxiety disorder, and hyperlipidemia, reported an incident involving a certified nursing assistant (CNA) during personal care. The resident alleged inappropriate handling and possible abuse. Despite this allegation, a full body skin assessment was not performed immediately after the incident. The Director of Staff Development and the Director of Nursing both acknowledged that the absence of a timely skin assessment delayed the identification and treatment of any potential injuries or changes in the resident's condition. A third resident, diagnosed with vascular dementia, anxiety disorder, depression, and diabetes mellitus, had persistently elevated blood sugar readings over several days, despite being on a sliding scale insulin regimen and the addition of long-acting insulin. Nursing staff did not notify the physician about the continued hyperglycemia, nor did they seek new orders or adjustments to the treatment plan. Both the LVNs and the Director of Nursing confirmed that the lack of physician notification and intervention meant the resident's blood sugar remained uncontrolled for an extended period.