Failure to Monitor and Assess Residents with Acute Illnesses Resulting in Hospitalization
Penalty
Summary
The facility failed to comprehensively assess and appropriately monitor two residents with acute illnesses, including influenza, which resulted in hospitalization. For one resident with a history of COPD, CHF, diabetes, and chronic respiratory failure, staff identified a change in condition marked by confusion, poor appetite, and a cough. Although the provider was notified and laboratory tests were ordered, the resident's records lacked documentation of ongoing assessment and monitoring of vital signs, respiratory status, or infection after the change in condition was noted. There was no evidence of additional monitoring or assessment between the time the change was identified and the resident's transfer to the hospital, despite staff interviews indicating that more frequent monitoring should have occurred. The resident was later hospitalized with diagnoses including influenza A, hypoxia, sepsis, and acute respiratory failure. Another resident with CHF, dementia, and an indwelling catheter experienced a change in condition characterized by foul-smelling urine and altered mental status. The provider was notified via a written message rather than an immediate call, and laboratory tests for infection and influenza were ordered. The resident's records did not show evidence of ongoing assessment or monitoring of vital signs, respiratory status, or urinary symptoms after the change in condition. Despite orders for daily monitoring and documentation, there were no corresponding progress notes or evidence of additional monitoring. The resident was later hospitalized with influenza A, sepsis, and a high fever. Interviews with nursing staff and the DON confirmed that the expected standard of care was not met, as there was a lack of timely and thorough assessment and monitoring following the residents' changes in condition. Facility policies required prompt provider notification and active surveillance for illness, especially during an influenza outbreak, but these were not followed. The records lacked documentation of the required assessments and monitoring, and there was a delay in provider notification and treatment for both residents.