Failure to Obtain Ordered Labs and Recognize Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to obtain laboratory tests as ordered by the physician and did not ensure effective communication among staff to recognize and respond to a resident's change in condition. The resident, who had a history of stroke, anemia, and hypertension, was admitted for rehabilitation and initially made progress in therapy, including self-feeding, ambulating with assistance, and communicating needs through gestures. Despite a physician's documented plan for specific lab work, no orders were entered or completed for these labs during the resident's stay. In the days leading up to the resident's hospital transfer, multiple staff members—including therapists and nurse aides—observed a significant decline in the resident's functional status. Symptoms included dizziness, lightheadedness, nausea, altered responsiveness, poor appetite, dry mouth, and decreased ability to communicate or participate in therapy. These changes were reported to nursing staff, but there was a breakdown in communication, and the severity of the decline was not recognized or escalated appropriately. Nursing documentation was inconsistent, and some nurses were unaware of the resident's prior progress or the extent of her decline. After testing positive for COVID, the resident did not receive evaluation or medical treatment for her infection or her deteriorating condition until she was transferred to the hospital several days later. At the hospital, she was found to be septic due to COVID infection and had gastrointestinal bleeding resulting in critically low hemoglobin, requiring intensive care and blood transfusions. The lack of timely assessment, failure to follow physician orders for labs, and poor communication among staff contributed to the delay in recognizing and treating the resident's acute medical needs.