Failure to Notify Physician and Assess Resident During Change in Condition and Procedure
Penalty
Summary
A deficiency occurred when a resident, recently readmitted after hospitalization for multiple complex conditions including status post spinal surgery, diabetes mellitus, and morbid obesity, experienced a significant change in mental status and became resistant to care during a physician-ordered catheterization procedure. Despite the resident's confusion, resistance, and expressed refusal, the LPN did not notify the facility healthcare practitioner or the Registered Nurse (RN) on duty of the mental status change or the difficulty encountered during the procedure. Multiple staff members were involved in physically restraining the resident to complete the catheterization, and the resident later reported the experience as traumatic and distressing. There was no documentation by the RN or LPN of an assessment or follow-up after the procedure, nor was there evidence that the physician was notified of the resident's change in condition, the results of the bladder scan, or the challenges faced during catheterization. The RN did not reassess the resident or provide a shift report to the oncoming nurse, and no vital signs or behavioral monitoring were documented after the procedure. Additionally, there was no comprehensive care plan addressing the resident's urinary retention or mental status changes until several days later, after the resident reported the incident as abuse. Interviews with staff confirmed that professional standards of care were not followed, including the failure to review orders prior to procedures, lack of notification to the physician regarding the resident's resistance and mental status change, and absence of RN assessment. The facility's own policy required immediate physician notification for significant changes in condition, which was not adhered to in this case. The events led to the resident experiencing psychosocial harm and a lack of appropriate monitoring and intervention during a critical change in their condition.