Failure to Timely Assess, Monitor, and Report Resident Condition Changes
Penalty
Summary
The facility failed to timely assess, monitor, and report significant changes in resident condition, specifically regarding a fall incident and weight gain. In one case, a resident with severe cognitive impairment was pushed to the floor by another resident. Staff present at the time did not ensure a licensed nurse assessed the resident immediately after the incident, nor were 15-minute checks, neurological assessments, or vital signs documented as directed. The incident was not discovered or properly investigated until four days later, and there was no evidence of a physical assessment by a licensed nurse until that time. The facility also lacked a clear policy or procedure for staff to follow when a fall occurs, and the Director of Nursing confirmed that education on documentation and notification was provided only during staff training or as needed for agency staff. In another case, a resident with multiple diagnoses, including heart failure and cirrhosis, had physician orders for daily weights and specific instructions to notify the provider if there was a two-pound weight gain in 24 hours or a five-pound gain in a week. The resident's medical record and treatment administration record showed several days where weights were not documented, and there was no evidence that the provider was notified when the resident experienced weight gains that met the criteria for notification. The resident reported difficulty finding working scales and required staff assistance to obtain weights, contradicting the DON's statement that the resident weighed himself. There was no documentation of weight refusals or provider notifications as required by the care plan and physician orders. These deficiencies were identified through medical record review, staff and resident interviews, and review of facility policies. The findings revealed lapses in timely assessment, monitoring, and communication regarding significant changes in resident condition, as well as a lack of clear procedures for staff to follow in the event of a fall or significant weight change.