Failure to Recognize and Respond to Change of Condition and Inadequate Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who experienced changes in condition. For one resident with a history of Alzheimer’s disease, kidney disease, and an indwelling Foley catheter, multiple CNAs observed and reported significant changes including increased lethargy, decreased intake, and changes in urine color and output. Despite these reports, nursing staff did not complete a nursing assessment, did not monitor the resident’s condition, and did not notify the provider of the changes. Documentation of intake and output was inconsistent and incomplete, with staff using non-quantitative symbols instead of actual measurements, making it impossible to determine the resident’s fluid status. The resident’s condition deteriorated over several days, culminating in hospitalization for severe sepsis, bacteremia, and UTI, and ultimately resulted in death. Another resident was subjected to a straight catheterization by an LPN to obtain a urine sample without a physician’s order, which is not permitted by professional standards or facility policy. The resident reported pain and discomfort from the procedure, which was attempted multiple times, including one attempt that resulted in a contaminated sample. Additionally, this resident had multiple wounds that were not consistently assessed or measured, and there was no documentation of an admission skin assessment or classification of the wounds. Physician orders for wound care were not consistently followed, and wound documentation was incomplete and lacked necessary details such as tunneling and depth. Interviews with staff and review of facility documentation revealed a lack of clear responsibility for monitoring intake and output, inconsistent documentation practices, and failures to notify providers of significant changes in residents’ conditions. The facility’s own policies required immediate notification of changes in condition and adherence to the nursing process, but these were not followed. These failures resulted in immediate jeopardy for one resident and demonstrated a pattern of deficient practice in the recognition, assessment, and management of changes in condition and wound care.
Removal Plan
- Educate all nursing staff, including agency, on recognition of change of condition and immediate reporting to the nurse. The nurse will perform a head to toe assessment and notify the PCP of findings.
- Educate staff on recognizing a change of condition, including changes in mental status, intake or output, urine color, communication, pain, swelling, weakness, and skin color. Use the stop and watch warning tool.
- Educate staff to report possible change of condition to the nurse immediately. The nurse will do a full assessment, call the MD, follow MD directions, document the change, notify the POA/MCO, continue monitoring, and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Educate nurses on completing a head to toe assessment, including vitals, pain, GI, respiratory, cardiac, GU symptoms, and immediate MD notification. Continue monitoring and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Train staff on properly recording fluid intake and food percentage for each resident on each shift. CNA assigned to the dining room will record all intakes and ensure residents eating in rooms are recorded. CNA is responsible for charting this information in the resident’s chart.
- Educate staff on recording intakes using the spreadsheet for each meal, properly documenting in the resident’s chart, noting if the amount is off baseline, and immediately reporting to the nurse.
- Educate staff to report immediately to the nurse if the resident’s intake or output has decreased.
- Educate staff on the 24-hour board binder and proper recording of change of condition to be reviewed during report off.
- Sweep the building for any changes in condition.
- Review policy related to changes of condition and notification of changes.
- Implement 24-hour board binder for monitoring and review during stand up.
- Implement process for monitoring fluid intake and output and when to notify MD/NP.
- Review head to toe and system-specific assessment for intake and output.
- Implement system to report off resident change of condition to next shift.
- The DON or designee will conduct audits of charting for change of condition and documentation.
- The DON or designee will conduct audits of the 24-hour report for properly completed and documented assessments and MD notification.
- The DON or designee will conduct audits to ensure changes of condition are recognized, assessments completed, and MD notification.
- The DON or designee will conduct audits of intake sheets and proper documentation in charts.
- The DON or designee will conduct audits of output documentation and proper reporting of inadequate output.
- The DON or designee will conduct audits of the intake sheet and proper documentation and reporting of decreased intake.
- The DON or designee will conduct audits on proper reporting of change of condition to the next shift.
- Review all facility actions, education, and audits at QAPI.