Failure to Timely Identify and Document Change in Condition
Penalty
Summary
The facility failed to identify and respond to a resident's change in condition in a timely manner. A female resident with a history of peripheral vascular disease, chronic heart failure, NSTEMI, atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness was noted to have refused breakfast and lunch, consumed minimal fluids, and complained of not feeling well. She also reported shortness of breath, and her oxygen saturation was recorded at 89% on room air. Oxygen was applied, and Tylenol was administered for a mild fever. Two hours later, two nurses reassessed her and observed abdominal breathing and an irregular heart rate, prompting a call to the nurse practitioner and a decision to send her to the emergency room, where she was later admitted for a non-STEMI heart attack. Interview and record review revealed that the nurse did not document all assessments or communications with the nurse practitioner regarding the resident's condition. The nurse acknowledged that documentation was limited to a single progress note and that she should have documented more. The facility's policy requires prompt notification and documentation of significant changes in a resident's condition, including consultation with the physician and notification of the resident's representative, but this process was not fully followed in this case.