Failure to Ensure Timely Medical Treatment After Change in Condition
Penalty
Summary
The facility failed to ensure timely medical treatment for a resident who experienced a significant change in condition. On the morning in question, the resident exhibited garbled speech, confusion, inability to hold a cup, and difficulty following commands, as observed by both family and staff, including a CNA, OT, and speech and physical therapy staff. Despite these concerning symptoms, the LPN responsible for the resident did not obtain vital signs or notify the nurse practitioner of the resident's worsening condition, as required by facility policy. The nurse practitioner, who had seen the resident earlier and instructed the LPN to monitor and report any changes, was not contacted when the resident's condition declined further. The resident's electronic medical record lacked documentation of vital signs for the day, and multiple staff members noted the resident's confusion and inability to participate in therapy. The DON later confirmed that the LPN should have taken vital signs and notified the nurse practitioner when the resident's condition deteriorated. This failure to follow established protocols for monitoring and reporting changes in condition resulted in the resident suffering an acute ischemic stroke with receptive aphasia.