Failure to Ensure RN Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when a resident experienced a significant change in condition involving a fracture of the left fibula and tibia. The resident, who had severe cognitive impairment, was found in distress with swelling and pain in her left lower leg. Certified nurse aides alerted LPNs, who assessed the resident, administered pain medication, and arranged for a STAT X-ray. However, there was no documentation that a registered nurse (RN) performed a comprehensive assessment following the change in condition, as required by professional standards and facility policy. Documentation in the electronic medical record and incident reports showed inconsistencies in the timing of events and lacked evidence of an RN assessment at the time of the injury. The LPNs involved did not notify the RN on duty to conduct an assessment, and the director of nursing (DON), who was off-site, did not instruct staff to ensure an RN assessment was completed. The DON and LPNs communicated about the incident and X-ray results, but the RN on duty never observed or assessed the resident after the injury or prior to hospital transfer. Staff interviews confirmed that the process for a change in condition was not followed, as the LPNs did not involve the RN on duty for assessment. The DON acknowledged that she did not assess the resident and relied on communication with the on-call LPN. The lack of RN assessment after a significant change in condition, specifically a suspected fracture, constituted a failure to meet professional standards of nursing care as outlined in both professional references and facility policy.