Failure to Assess and Notify Medical Providers During Resident Change in Condition
Penalty
Summary
The facility failed to properly assess and monitor residents experiencing a change in condition, resulting in significant deficiencies for multiple residents. In one case, a resident with multiple comorbidities, including acute kidney failure, diabetes, and congestive heart failure, was documented as having a Do Not Resuscitate (DNR) order with comfort-focused measures. Despite clear changes in the resident's condition, such as refusal to eat, drink, or take medications, and increased non-responsiveness, there was no documentation that the medical practitioner was notified in a timely manner. Vital signs were inconsistently recorded, and when the resident's condition further declined, the medical provider was still not notified until after the resident was sent to the hospital, where he later expired. Another resident experienced a change in condition that was reported by CNAs to the assigned nurse, but there was a delay in assessment and documentation. Staff reported the resident was not acting himself, was dizzy, and eventually became unresponsive. Despite these reports, there was no documentation of vital signs or a thorough assessment prior to the resident being transferred to the hospital, where he was pronounced deceased. Interviews with staff revealed inconsistencies in communication and documentation, with some staff stating they reported changes while others did not recall being notified. The medical record lacked evidence of timely notification to the physician and appropriate documentation of assessments. A third resident was found unresponsive during wound care, and while CPR was initiated and emergency services were called, there was no documentation of vital signs or a thorough assessment prior to the intervention. The facility's policy required immediate assessment and physician notification upon identification of a change in condition, but this was not consistently followed. The lack of timely assessment, documentation, and communication with medical providers contributed to delays in medical intervention and ultimately resulted in adverse outcomes for the residents involved.