Failure to Assess and Document Resident After Unresponsiveness
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed and documented required physical and neurological assessments for a resident who was found unresponsive in their room. According to the report, a Certified Nursing Assistant (CNA) discovered the resident sitting on the floor, leaning against a recliner, and notified the RN. Upon arrival, the RN attempted to arouse the resident, who remained unresponsive, and then left the room to call 911 and the physician, leaving the CNA with the resident. The RN did not perform or document a full assessment, including vital signs, lung sounds, oxygen saturation, blood glucose, or neurological checks, as required by facility policy. The facility's policy on observing, recording, and reporting condition changes specifies that after a fall, injury, or change in condition, staff must monitor for a range of symptoms, check vital signs, and document all observations and assessments. The RN's job description also requires charting all accidents or incidents and providing detailed, objective documentation of care and resident response. In this incident, the RN only checked the resident's pulse, which was not documented, and did not perform any other assessments or instruct the CNA to do so. The resident continued to exhibit snoring respirations until EMS arrived, at which point CPR was initiated. Interviews with the CNA, RN, Director of Nursing (DON), and the resident's physician confirmed that the expected assessments and documentation were not completed. Both the DON and the physician stated that they would have expected ongoing assessments and documentation until EMS arrived, in accordance with facility policy. The lack of assessment and documentation was also evident in the resident's electronic health record and the RN's written statement, which did not include required details about the resident's condition or care provided during the event.