Failure to Provide Timely Medical Intervention After Acute Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and obtain medical intervention for a resident following an acute change in condition. The resident, who had diagnoses including dysphagia and hypertension and required assistance with activities of daily living, was admitted with no terminal condition noted. Physician orders included increased fluid intake for dehydration and monitoring of fluid intake, but documentation of actual fluid intake was lacking. The resident experienced multiple episodes of emesis, decreased fluid intake, and adventitious lung sounds, yet there was no evidence that the physician or family were notified or that effective interventions were initiated at that time. On the day prior to the resident's death, staff documented further emesis, possible aspiration, and crackles throughout the lung fields. Orders were received for anti-emetic medication, a clear liquid diet, and intravenous fluids, and a STAT chest x-ray was ordered at the request of the resident's daughter. The x-ray, performed overnight, showed bilateral pulmonary infiltrates and cardiomegaly. At 1:07 A.M., the resident was found to have labored breathing, a respiratory rate of 39, oxygen saturation of 60% on oxygen, no obtainable blood pressure, and a heart rate of 39. Despite these critical findings, there was no documentation that the physician or family were notified, and no additional interventions were provided. There was no further documentation between 1:13 A.M. and 6:02 A.M., when the resident was found without vital signs. Interviews with facility leadership and medical providers confirmed that the nurse did not notify the physician or family of the resident's acute change in condition, as required by facility policy. The lack of timely notification and intervention following the resident's significant change in status resulted in actual harm.