Failure to Consistently Monitor and Record Vital Signs for Resident with COVID
Penalty
Summary
Nursing staff failed to consistently monitor and record all required vital signs for a female long-term resident diagnosed with COVID infection, despite physician orders to do so every shift. The resident, who had advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder, hypertension, and dysphasia, was placed in isolation after her COVID diagnosis. Review of her medical records revealed that from the date of diagnosis through her transfer to the hospital, vital signs such as pulse, respiratory rate, and pulse oximetry were frequently omitted, with multiple days showing no documentation of these parameters. This incomplete monitoring occurred even after the resident's family expressed concern about her condition and changes in her level of consciousness. Progress notes indicated that after the family raised concerns, nursing staff administered a nebulizer treatment and documented some lung assessments, but did not perform a full set of vital signs or a thorough nursing assessment as would be standard practice. The Unit Manager confirmed during an interview that the expectation was for complete vital sign monitoring twice daily, and acknowledged that the records did not meet this standard. The lack of consistent and complete vital sign monitoring represented a failure to provide the standard of nursing care as required by the resident's condition and physician orders.