Failure to Plan for Predictable Condition Decline and Timely Physician Consultation
Penalty
Summary
The facility failed to adequately identify and plan for a predictable decline in a resident's condition that would require timely health care decision-making and guidance for direct care staff. The resident, an elderly male with multiple chronic conditions including Parkinson's disease, dementia, severe dysphagia, and congestive heart failure, experienced repeated hospitalizations for aspiration pneumonia and ultimately died following a significant change in condition. Although the resident had an Advanced Health Care Directive (AHCD) and a designated Power of Attorney (POA), there was no Provider Order for Life-Sustaining Treatment (POLST) in place, and the care plan did not address specific scenarios or provide clear guidance for staff in the event of a rapid decline. On the day of the incident, the resident was fed by a private caregiver and later developed unstable vital signs, including low blood pressure and oxygen saturation. Nursing staff responded by administering a nebulizer treatment and increasing oxygen support, but there was a delay in consulting the physician about the change in condition. The POA was notified and ultimately made the decision to transfer the resident to the hospital, but the process was delayed as staff sought direction from both the POA and the physician. Documentation and interviews revealed that while the POA was actively involved and wished to be notified of any changes, there was no advance planning or interdisciplinary team discussion to guide staff on how to respond to such predictable emergencies. Facility policies required staff to notify physicians of changes in condition and to arrange for emergency care as needed, but these steps were not followed promptly in this case. The lack of a POLST and absence of clear, advance guidance in the care plan contributed to confusion and delay in the resident's transfer to a higher level of care. The deficiency was identified based on interviews, record reviews, and policy analysis, which showed that the facility did not ensure staff had the necessary information and planning to act decisively in a foreseeable situation.