Failure to Complete Timely RN Assessment After Change in Condition
Penalty
Summary
A deficiency occurred when a registered nurse failed to complete and document a timely assessment following a significant change in a resident's condition. The resident, who was cognitively impaired and required extensive assistance with daily care, was initially found on the floor with a minor leg injury and no complaints of pain. Later the same day, the resident began to experience new severe pain and exhibited a markedly low blood pressure of 70/44, along with increased respirations. Although the RN supervisor and Director of Nursing were notified of these changes, there was no documented evidence that a registered nurse assessed the resident at that time. The facility's failure to ensure a registered nurse performed and documented an assessment after the resident's change in condition was confirmed through review of clinical records, investigative documents, and staff interviews. The Director of Nursing acknowledged that an RN assessment should have been completed and recorded in the medical record, as required by professional standards and state regulations.