Failure to Timely Respond to Change in Condition, Abnormal Vitals, and Antibiotic Administration
Penalty
Summary
The facility failed to provide timely and appropriate care in response to changes in condition and abnormal vital signs for multiple residents. For one resident with a history of heart failure, atrial fibrillation, and hyperkalemia, there were repeated instances of abnormal pulse readings documented in the medical record, including bradycardia with heart rates as low as 37 bpm. Despite these abnormal findings, there was no evidence of reassessment, practitioner notification, or follow-up interventions documented. Interviews with the nurse practitioner and DON confirmed that the facility's policy required reassessment and provider notification for out-of-range vital signs, but this was not carried out as required. Another resident, admitted for rehabilitation with diagnoses including cellulitis and UTI, experienced a three-day delay in receiving prescribed antibiotics after transfer from the hospital. The resident reported the delay to staff, and it was discovered that the antibiotic was not ordered because it was missing from the medication list, despite being included in the hospital discharge summary and physician progress notes. The DON and ADON confirmed that the facility's process relied solely on the medication list for new admissions, and did not include review of the discharge summary or progress notes, resulting in the omission and delay of critical antibiotic therapy. A third resident, admitted following hernia surgery and with a history of COPD, experienced a decline in condition characterized by abnormal vital signs, including low blood pressure, high pulse, increased respiratory rate, decreased oxygen saturation, and persistent abdominal pain, nausea, and vomiting. Although a STAT abdominal x-ray was ordered, the order was not processed as STAT, resulting in a delay of over 24 hours before the x-ray was completed and results were communicated. Documentation did not reflect timely assessment or intervention in response to the resident's abnormal vital signs or worsening symptoms, and the resident was ultimately transferred to the hospital after continued decline.