Failure to Assess and Document Changes of Condition and Treatment
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards of practice for three residents, resulting in deficiencies related to assessment and documentation during changes of condition. In one case, a resident with multiple diagnoses, including seizure disorder, diabetes, and cognitive impairment, experienced a fall and subsequently developed increased pain and decreased range of motion. Despite these changes, there was a delay in further assessment and provider notification, and pain assessments and interventions were inconsistently documented. The resident's care plan did not specify a pain goal or PRN pain medication administration, and non-pharmacological interventions were not consistently attempted or documented. Two other residents, both of whom experienced changes of condition related to infection and were started on antibiotic therapy, did not have documented assessments throughout the course of their treatment. For these residents, there was a lack of ongoing shift-by-shift documentation of vital signs and clinical status during the antibiotic course, as required by facility expectations and professional standards. Interviews with facility staff, including the DON, Nurse Manager, and Infection Preventionist, confirmed that ongoing assessment and documentation were expected but not performed. The facility did not have a formal Change of Condition policy but stated adherence to AMDA guidelines, which require further assessment and provider notification for acute changes such as new or worsening pain, especially following trauma. The lack of timely assessment, documentation, and provider notification for residents experiencing changes of condition, including after falls and during infection treatment, directly led to the identified deficiencies.