Failure to Timely Identify and Respond to Acute Change in Condition Resulting in Harm
Penalty
Summary
A deficiency occurred when staff failed to timely and adequately identify and respond to an acute change in a resident's medical condition, resulting in a delay in medical intervention and hospital care. The resident, who had a history of acute respiratory failure, congestive heart failure, high blood pressure, cardiomegaly, atrial fibrillation, and a previous hemorrhagic stroke, was admitted for short-term rehabilitation with the goal of returning home. On the night in question, the resident experienced an unwitnessed fall, reported not feeling well, and had multiple episodes of vomiting. Despite these symptoms and abnormal vital signs, including persistent hypotension, the staff did not initiate ordered intravenous (IV) fluids until approximately eight hours after the order was given by the Certified Nurse Practitioner (CNP). Throughout the day, the resident continued to exhibit concerning symptoms, such as refusing meals, ongoing vomiting, and low blood pressure readings. The CNP assessed the resident in the morning, ordered a chest x-ray, IV fluids, and a urinalysis, and noted abnormal laboratory results, including elevated white blood cell count and blood urea nitrogen. However, the IV fluids were not started until late in the afternoon, after a second episode of vomiting, and the urinalysis was not obtained. Staff interviews revealed confusion about the urgency of the IV fluid order, with some believing it was not a STAT order and therefore could be delayed. Later that day, the resident was found unresponsive and required cardiopulmonary resuscitation (CPR). Emergency Medical Services were called, and the resident was transported to the hospital, where CPR was continued, but the resident was ultimately pronounced deceased. The facility's policy required timely assessment and intervention for changes in condition, but the delay in initiating medical orders and failure to recognize the severity of the resident's symptoms contributed to actual harm.