Failure to Communicate Change in Condition Resulting in Delay of Treatment
Penalty
Summary
Facility staff failed to ensure prompt communication of a significant change in condition for one resident, resulting in a delay in treatment. The resident, who had a history of alcohol cirrhosis with ascites, hepatic encephalopathy, pleural effusion, heart failure, and generalized swelling, experienced increasing fatigue, confusion, and difficulty eating. Certified Nursing Assistants (CNAs) observed these changes, including the resident becoming more tired, needing assistance with meals, eating less, and displaying confusion and altered speech. Although CNAs reported some changes to licensed nurses, there were inconsistencies in communication, with one CNA later admitting to the Assistant Administrator that she had not reported the change in condition to the nurse as initially claimed. Licensed nurses did not receive complete or timely information about the resident's altered mental status and physical decline. As a result, the resident's significant change in condition, including weakness, dysphagia, and altered level of consciousness with abnormal vital signs, was not promptly communicated to the physician. The delay in recognizing and reporting these changes led to a delay in treatment, and the resident was eventually sent to the hospital after further decline was noted. Review of facility policy confirmed that staff were required to report such changes to licensed nurses, but this procedure was not followed.