Failure to Provide Timely Assessment, Monitoring, and Physician Notification for Changes in Condition and Treatment Needs
Penalty
Summary
The facility failed to provide necessary care and treatment for several residents, resulting in significant deficiencies. For one resident with a history of congestive heart failure, diabetes, and end-stage renal disease, staff did not properly assess or monitor the resident after a change in condition was observed, specifically shivering and shaking. The LVN on duty only checked the resident's temperature, provided a blanket, and did not document the findings or notify the physician. The LVN also failed to inform the incoming nurse and RN supervisor about the change in condition during shift handoff. As a result, the resident was not monitored every two hours as required, and was later found unresponsive and pronounced dead after unsuccessful resuscitation efforts. Interviews confirmed that staff recognized the symptoms as a change in condition but did not follow protocol for assessment, documentation, or notification. Another resident with a diagnosis of constipation and other comorbidities was not provided with prescribed medications for constipation after having no bowel movement for three days. The care plan required monitoring and administration of PRN medications for constipation, but staff failed to assess, monitor, or administer the necessary medications as ordered. The resident reported ongoing constipation to staff, but the issue was not addressed, and documentation confirmed that no PRN medications were given during the period of no bowel movement. Staff interviews revealed a lack of monitoring and follow-through on bowel movement frequency and medication administration. Additional deficiencies included failure to document and obtain orders for nasogastric (NG) tube reinsertion for a resident who repeatedly pulled out the tube, as well as failure to document the location of tube placement. The care plan was not updated after repeated incidents, and required documentation was missing. In another case, after a resident on clopidogrel sustained a fall, the physician was not notified of the resident's antiplatelet therapy, preventing appropriate evaluation for internal bleeding. Facility policies and staff interviews confirmed that these actions were required but not performed, resulting in incomplete care and documentation.