Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a significant change in condition that was not promptly recognized, addressed, or documented by staff. Over several days, the resident became increasingly lethargic, stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely follow-up or documentation regarding his post-fall status, pain, lethargy, or decreased functional abilities. Multiple staff interviews revealed that the resident's decline was observed by CNAs and nurses, including his staying in bed, not eating independently, and not smoking as usual. Some staff noted the changes but did not consistently notify the nurse or document the observations. Nurses who were aware of the changes did not escalate the concerns or notify the nurse practitioner (NP) or physician in a timely manner. The resident's responsible party was also not informed of the changes until after a care plan meeting, at which point the resident was found to be difficult to arouse and not at his baseline. The resident was eventually assessed as febrile, hypertensive, and unresponsive, leading to his transfer to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required prompt notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed. The failure to recognize and act upon the resident's change in condition resulted in the identification of Immediate Jeopardy by surveyors.