Failure to Recognize and Report Change in Condition Resulting in Delay of Care
Penalty
Summary
Nursing staff failed to recognize and report a significant change in condition for one of eight sampled residents, who had multiple complex medical diagnoses including atrial fibrillation, aortic valve disorder, bilateral pneumonia, COPD, and several mental health conditions. The resident was cognitively intact and responsible for their own care decisions. On the date in question, the resident's blood pressure was recorded at a significantly low level (82/64 mmHg), with documentation noting the abnormal value but lacking details such as multiple measurements or the resident's position during assessment. Although there was a physician order to push fluids, there was no documentation indicating that the resident was sent for further evaluation at that time. Later that evening, police were called to the facility, and after discussions with the resident and their daughter, the resident requested to be sent to the hospital due to concerns about a possible allergic reaction. The medical director was notified, and EMS was called to transfer the resident. The Director of Nursing confirmed that the facility's policy for notification of changes in condition was not followed, and acknowledged that the resident experienced a delay in care and should have been sent to the hospital earlier. The resident was subsequently admitted to a local hospital for an extended period and expressed dissatisfaction with the care received at the facility.