Failure to Respond to Acute Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with multiple complex medical diagnoses, including morbid obesity, heart failure, sleep apnea, and respiratory failure. The resident was noted by therapy staff to have a significant decline in health, including hypoxemia, tachycardia, excessive daytime sleepiness, and lethargy while in therapy. Despite these abnormal findings, there was no evidence that a comprehensive nursing assessment was performed, nor were individualized interventions implemented. The therapy staff notified the Assistant Director of Nursing (ADON), who observed the resident and communicated with the on-site nurse practitioner (NP), but the NP did not assess the resident, and no further action was taken to address the acute change in condition. Throughout the day, the resident continued to exhibit increased somnolence, lethargy, and loud snoring, which were not comprehensively addressed by nursing staff. Documentation showed that the resident's oxygen saturation levels were critically low and heart rate was elevated during therapy, and the resident was unable to participate in therapy due to these symptoms. Despite these clear signs of deterioration, there was no evidence of timely communication with the medical provider, no comprehensive assessment, and no escalation of care. Nursing documentation was incomplete, and staff interviews revealed a lack of awareness and follow-through regarding the resident's change in condition. Later that evening, the resident was found unresponsive and without vital signs by an LPN during medication administration. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced deceased. The cause of death was determined to be acute hypoxic and hypercapnic respiratory failure. The facility's failure to recognize, assess, and respond to the resident's acute change in condition, as well as the lack of communication and documentation, directly contributed to the deficiency and resulted in actual harm and death.