Failure to Provide Immediate Emergency Care for Resident with Acute Change in Condition
Penalty
Summary
The facility failed to provide immediate emergency care to a resident who experienced an acute change in mental status and severely elevated blood pressure. Despite the resident presenting with altered mental status, left-sided gaze deviation, and a blood pressure reading as high as 220/138 mmHg, nursing staff did not promptly assess or intervene according to the facility's emergency protocols. The resident, who had a history of hypertension, diabetes, hemiplegia, and epilepsy, was not immediately sent to the hospital, and there was a delay of over three hours from the initial observation of the change in condition to the arrival of emergency medical services. Documentation and interviews revealed that the resident was found unresponsive and staring blankly, with family and staff noting facial drooping and lack of responsiveness. The LVN on duty suspected a seizure due to the resident's history but did not perform a full assessment for stroke or check the resident's blood sugar, despite orders to do so in cases of altered consciousness. The LVN also failed to document vital signs and interventions in a timely manner and delayed calling 911, only doing so after consulting with other staff and family members. The facility's policies required immediate emergency intervention and notification of medical personnel for such acute changes, but these were not followed. As a result of these failures, the resident remained in a compromised state for several hours, ultimately suffering an intracerebral hemorrhage as confirmed by hospital imaging. The resident was intubated and transferred to a higher level of care, but subsequently died. The facility's lack of immediate assessment, failure to follow emergency protocols, and delayed transfer to acute care directly contributed to the resident not receiving timely and appropriate emergency treatment.