Failure to Monitor and Notify Physician of Resident's Change in Condition
Penalty
Summary
A resident with a history of Alzheimer's disease, acute kidney failure, hypertensive heart disease, and chronic kidney disease was readmitted to the facility and had physician's orders in place for diuretic use, monitoring for edema, congestion, and weight changes every shift, as well as specific orders to assess and document respiratory status every shift for three days. Despite these orders, there was no evidence that the resident's respiratory status was assessed and documented as required on multiple shifts. Additionally, staff failed to monitor and document the presence of edema and congestion as ordered. Surveyor observations revealed that the resident exhibited swelling in the lower legs and a congested, non-productive cough over several days. Staff interviews confirmed that the resident was observed coughing, but assessments were not performed or documented, and the physician was not notified of the change in condition in a timely manner. One LPN admitted to documenting that an assessment was completed when it was not, and only assessed the resident for edema after the surveyor brought the issue to her attention. The resident was found to have severe pitting edema at that time. The facility's policy required notification of the physician and responsible party when a change in condition occurred, including the need to alter medical treatment. However, the physician was not notified of the resident's change in condition until several days after the initial assessment, and only after the surveyor intervened. Staff and leadership interviews confirmed that the expected standard of care was not met, as the resident was not assessed or monitored according to physician orders and professional standards of practice.