Failure to Ensure Nursing Staff Competency in Recognizing and Responding to Resident Changes in Condition
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in recognizing and responding to changes in condition, following physician orders, and reporting abnormal laboratory results for three residents. For one resident with a history of metabolic encephalopathy, acute renal failure, atrial fibrillation, and chronic kidney disease, multiple physician orders for diagnostic tests, including a chest x-ray and urinalysis, were not completed, and the medical team was not notified of these omissions. Additionally, critical laboratory results for sodium and chloride were not obtained, and again, there was no documentation of physician notification. The resident subsequently experienced a significant change in condition, including altered mental status and hypoxia, leading to hospitalization for acute hypoxic respiratory failure, severe hypernatremia, and acute renal insufficiency. Another resident with heart failure, a cardiac pacemaker, and hypertension had a stat troponin test ordered, which returned an elevated result. The abnormal result was available in the facility’s lab portal, but the medical team was not notified until the advanced registered nurse practitioner reviewed the labs the following day. Facility staff interviews confirmed that nurses are expected to notify the medical team of all test results, especially abnormal ones, and to document this communication, but this did not occur in this instance. A third resident, with a history of major depressive disorder, diabetes, anemia, hypertension, chronic kidney disease, and congestive heart failure, reported feeling unwell and experienced continuous vomiting for several days. Despite repeated complaints and documentation of symptoms, there was a delay in obtaining and acting upon physician orders for diagnostic tests and a change in condition assessment. Laboratory results eventually revealed critically elevated BUN and creatinine levels, but the resident had to call 911 himself to be transferred to the hospital. Staff interviews revealed uncertainty about the process and timeliness for stat labs and diagnostic tests, and the DON confirmed that a change in condition should have been completed earlier.