Failure to Assess and Intervene After Change in Condition and Fall
Penalty
Summary
The facility failed to provide proper assessments and interventions following changes in condition for two residents. One resident, with a history of Parkinson's Disease, coronary artery disease, and diabetes mellitus, experienced a significant change in condition, including fever, altered mental status, and abnormal vital signs. Despite staff reporting concerns about the resident's condition, including changes in bowel movements, decreased appetite, confusion, and fever, the nurse on duty did not assess the resident or notify the physician in a timely manner. The only intervention provided was a cold rag for the fever, and no PRN medication was administered. The physician was not notified until the resident's condition deteriorated significantly, at which point the resident was sent to the hospital and subsequently expired from sepsis due to aspiration pneumonia. Another resident, with dementia and multiple psychiatric and medical diagnoses, suffered an unwitnessed fall and complained of left hip pain. Staff failed to call the provider for a PRN pain order or for evaluation after the fall. The resident was not sent to the hospital until approximately 12 hours later, where a left hip fracture was diagnosed. Documentation and staff statements revealed that the resident was moved from the floor to the bed without the use of a mechanical lift, contrary to facility protocol, and that pain complaints were not adequately addressed or managed. The resident did not have a PRN pain medication order until after returning from the hospital. Facility policy required prompt assessment, notification of changes in condition, and appropriate interventions, including contacting the medical provider and documenting all significant changes. In both cases, staff failed to follow these protocols, resulting in delayed assessment, lack of timely intervention, and inadequate communication with medical providers and the DON. These failures were corroborated by staff interviews, clinical record reviews, and facility documentation.