Failure to Recognize and Respond to Changes in Condition and Adhere to Physician Orders
Penalty
Summary
The facility failed to recognize and respond appropriately to changes in condition for multiple residents, resulting in delayed treatment and unmet care needs. For one resident with a history of urinary tract infection, septic shock, respiratory issues, and heart disease, staff did not complete a change of condition assessment or notify the physician despite significant changes in orientation, oxygen saturation, blood pressure, and pulse. The resident experienced confusion, severe pain, and a drop in oxygen level, ultimately requiring hospitalization for septic shock. Interviews revealed that staff were aware of the resident's deteriorating condition but did not take timely action, and the physician and nurse practitioner were not informed of the critical changes. Another resident with a nephrostomy tube experienced a blocked tube and developed sepsis, leading to hospitalization. Staff failed to monitor and document nephrostomy output as ordered, and did not notify the physician when there was zero output. The resident and their representative reported pain and symptoms consistent with infection, but staff did not follow up or document these concerns, nor did they communicate with the provider as required by facility policy. Documentation gaps and lack of timely intervention contributed to the resident's adverse outcome. A third resident with a history of stroke and brain aneurysms reported new vision changes, dizziness, and head pressure. Although a nurse practitioner ordered a CT scan, there was no documentation of the visit, no alert charting initiated, and no monitoring or assessment of the resident's symptoms by licensed nurses. The order for imaging was not processed in a timely manner, and staff failed to notify the provider about worsening symptoms. Additional deficiencies were identified in the administration of PRN pain medication outside of ordered parameters and without required documentation, as well as in the management of a resident who experienced an unwitnessed fall with a head injury, where neurological checks and family notification were not completed as required.