Failure to Assess and Notify Provider During Acute Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, Parkinson's disease, congestive heart failure, and Lewy Body dementia, experienced an acute change in condition that was not properly assessed or managed by facility staff. The resident, who was typically able to feed himself with only setup help or cuing, became suddenly confused, lethargic, and unable to eat independently. Family members and another resident observed these significant changes, noting that the resident was not making sense and could not pick up his fork at lunch, which was a marked departure from his baseline. Despite these clear signs of acute deterioration, the nursing staff did not perform or document a nursing assessment, vital signs, or neurological checks on the day of the incident. The last recorded assessment and vital signs were from the previous day, and there was no evidence of timely provider notification or response. The assigned LPN recognized the change in the resident's condition around mid-morning, notified the family, and attempted to contact the provider by fax, but did not follow up with a phone call or escalate the situation when no response was received. The resident's condition remained unchanged for several hours before being sent to the emergency department. Upon arrival at the hospital, the resident was found to have a fresh brain bleed and was transferred to a higher level of care for neurosurgical evaluation and blood pressure management. The facility's own policy required prompt assessment, collection of pertinent information, and direct communication with providers in the event of an acute change of condition, but these steps were not followed. The Director of Nursing confirmed that the expected assessments and provider notifications were not completed during the critical period when the resident was exhibiting significant new deficits.