Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of a stage 4 sacral pressure ulcer was properly assessed and monitored following a change in condition. Staff observed that the resident, who was typically confused but active and frequently attempted to get up unassisted, was unusually inactive, did not use her call light, and did not attempt to get out of bed. Certified Nursing Assistants (CNAs) reported these changes to the nurse on duty, who responded only by checking vital signs multiple times throughout the shift but did not perform or document a comprehensive assessment or follow-up. Additionally, possible blood in the resident's urine was reported during the morning shift, but there was no documented assessment or notification to the nurse practitioner until the resident was sent to the hospital later that night. The facility's policy required prompt assessment, documentation, and notification of changes in a resident's condition, but these steps were not followed. The nurse on duty did not recall being informed of the possible blood in urine and did not document any assessment or communication regarding the resident's change in status. The Director of Nursing and Nurse Practitioner both confirmed that, according to facility policy and standard practice, a full assessment and notification should have occurred, and all actions should have been documented in the resident's medical record. The lack of timely assessment, documentation, and communication led to a delay in appropriate care for the resident.