Failure to Complete RN Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) assessment was completed when a resident experienced a change in condition. The resident, who had diagnoses including heart failure and was receiving hospice care, exhibited symptoms such as a moist, non-productive cough, moderate nasal congestion, hoarse voice, and a low-grade fever. Nursing notes documented these symptoms and the administration of Tylenol by an LPN, as well as ongoing monitoring of the resident’s temperature and encouragement of oral fluids. Despite these changes in the resident’s condition, there was no documented evidence that an RN performed an assessment at the time of the change. Further documentation showed that a hospice RN later assessed the resident, noting persistent symptoms, crackles in all lung lobes, a moist cough, and an oxygen saturation of 90% on room air. New orders were received from the hospice physician for antibiotics and adjustments to the resident’s medications. However, the facility’s records did not show that an RN from the facility assessed the resident during the initial change in condition, as required by state regulations. The Director of Nursing confirmed that an RN assessment should have been completed in such circumstances.