Failure to Identify and Respond to Change in Condition and Inadequate Physician Notification
Penalty
Summary
The facility failed to identify and appropriately respond to significant changes in condition for two residents, resulting in serious negative outcomes. For one resident with a history of urinary retention and recent hospitalization, there was a delay in scheduling a required urology follow-up, despite provider orders for timely consultation. The resident exhibited symptoms such as hematuria and pain with urination, and was started on antibiotics for a urinary tract infection (UTI). However, the antibiotic prescribed was not effective against the identified organism, as shown by culture and sensitivity results, yet the ineffective medication continued to be administered. Staff did not document or address additional symptoms such as sore throat, poor oral intake, and mental status changes, and failed to recognize or act upon a significant decline in the resident's condition, including not eating for two days and exhibiting confusion and weakness. The resident was only sent to the hospital after family intervention, where they were diagnosed with UTI, pneumonia, sepsis, and subsequently died from septic shock secondary to UTI and pneumonia. For another resident admitted with a femur fracture, pulmonary hypertension, and heart failure, the facility did not adequately monitor or respond to changes in vital signs and mental status. The resident experienced episodes of low blood pressure, bradycardia, and hypoglycemia, with documentation of lethargy and delayed responses. Despite these changes, there was no documentation that the physician was notified. When the resident's family expressed concern about cardiac issues and requested discharge against medical advice, the facility delayed implementing a STAT EKG order and did not complete the test before the resident was transferred to the hospital for respiratory distress. There was also a lack of documentation regarding the assessment and follow-up of the resident's cardiac and respiratory symptoms prior to transfer. Facility policy required staff to monitor and evaluate residents for changes in condition and to notify the physician team for direction when such changes were identified. In both cases, the facility failed to follow this policy, resulting in delayed recognition and treatment of acute medical issues, lack of appropriate physician notification, and insufficient documentation and follow-up of significant clinical changes.