Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a significant change in condition for a resident with multiple complex diagnoses, including an upper arm fracture, pancreatic cancer, and diabetes. On the day in question, the resident was noted by staff and the resident's representative to be slumped over in a wheelchair, difficult to arouse, and unresponsive to voice or visual commands. Despite these observations, no immediate assessment or vital signs were obtained by nursing staff, and the resident was not evaluated further before being sent to a scheduled medical appointment. Staff interviews revealed that both a nursing assistant and a registered nurse observed the resident's altered state, including increased sleepiness and physical weakness, but did not initiate a nursing assessment or notify a provider. The nurse stated that documentation was only required by exception and did not consider the resident's sleepiness as an indication for further assessment, relying on earlier normal vital signs. The resident was subsequently transported to a medical appointment in a compromised state, with staff at the clinic immediately recognizing the severity of the condition and calling emergency services. Emergency medical services documented extremely low blood pressure and altered level of consciousness, and the resident was admitted to the hospital in shock. The Director of Nursing confirmed that staff should have performed an immediate assessment and obtained vital signs when a resident appeared different. The failure to assess and respond to the resident's change in condition resulted in a missed opportunity to evaluate and treat a potentially life-threatening situation.