Failure to Assess, Monitor, and Escalate Care for Residents with Changes in Condition
Penalty
Summary
The facility failed to adequately assess and monitor residents experiencing changes in condition, did not notify physicians of continued decline, and did not transfer residents to higher levels of care in a timely manner. For four residents reviewed, these failures resulted in significant negative outcomes, including two deaths, one resident requiring intubation after hospital transfer, and another developing sepsis leading to shock. The surveyors found that physician-ordered interventions were not implemented, abnormal vital signs and lab results were not acted upon, and documentation and communication among staff and providers were lacking. One resident with a history of cardiac arrest and atrial fibrillation had physician orders for Cardizem and increased free water flushes that were never administered or transcribed. This resident exhibited persistent tachycardia and hypoxia over several days, with no follow-up or escalation of care until they were transferred to the hospital in respiratory distress and subsequently intubated. Another resident with end-stage renal disease and chronic anemia had a critically low hemoglobin level, but despite the facility's awareness and the resident's history of requiring hospital evaluation for low hemoglobin, there was a lack of timely notification and transfer. The resident ultimately expired in the hospital with a hemoglobin of 3.2, and documentation did not reflect any refusal of hospital transfer. A third resident, who was alert and oriented, requested to be sent to the hospital due to shortness of breath and refused dialysis, but there was no evidence of provider follow-up or reassessment. Orders for medication were not documented as given, and the resident was later found unresponsive and pronounced dead. The fourth resident, admitted with sepsis and toxic encephalopathy, had elevated heart rate and declining oxygen saturation, but vital signs were not consistently documented, and there was a lack of provider progress notes. The resident was eventually transferred to the hospital and diagnosed with septic shock. Facility policy required notification of significant changes, but this was not consistently followed, and documentation was incomplete or missing.
Removal Plan
- Assess current residents for a change in condition by reviewing labs and vital signs.
- Educate nursing staff on assessment, notifying the physician, implementing orders, and documentation.