Failure to Monitor Vital Signs per Care Plan Leads to Delayed UTI and Sepsis Identification
Penalty
Summary
The facility failed to promptly identify and monitor signs and symptoms of a urinary tract infection (UTI) for one resident, as required by the resident's care plan. The care plan, dated 1/23/2025, specified that the resident, who had a history of UTI and was at risk for further complications, should have vital signs monitored every shift. However, records and interviews confirmed that staff only checked the resident's vital signs once a week, with the last recorded check occurring on 5/28/2025, prior to a significant change in the resident's condition on 6/4/2025. The Director of Nursing acknowledged that the care plan was not followed and that the facility's policy for care plans was not implemented as required. The resident, who had diagnoses including encephalopathy, dementia, and anxiety, and was severely cognitively impaired and incontinent, experienced a rapid decline. On 6/4/2025, the resident developed severe shortness of breath, high fever, and low oxygen saturation, leading to emergency transfer to a general acute hospital, where the resident was diagnosed with UTI and sepsis. The failure to monitor vital signs as outlined in the care plan resulted in delayed identification of the resident's deteriorating condition.