Failure to Identify and Respond to Acute Change in Condition in Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards of practice for a resident with multiple complex medical conditions, including diabetes mellitus and congestive heart failure. The facility did not properly identify or intervene in the resident's acute change in condition, despite clear evidence of declining vital signs and symptoms such as persistent hypotension, lethargy, and altered mental status over a period exceeding 24 hours. Nursing staff documented low blood pressure readings, low oxygen saturation, and changes in the resident's behavior, such as increased sleepiness and confusion, but did not consistently notify the physician or take appropriate action in a timely manner. The resident's care plan and physician orders required regular monitoring of blood glucose and blood pressure, with specific parameters for holding medications and notifying the physician of abnormal findings. However, blood sugar checks were not performed as ordered, and staff failed to recognize or respond to signs of hypoglycemia and hypotension. Interviews revealed that both the resident and family members repeatedly expressed concerns about the resident's condition and requested blood sugar checks, but these concerns were not adequately addressed by nursing staff. Documentation gaps were also noted, with missing nursing notes and incomplete follow-up on abnormal vital signs. The situation escalated when the resident's condition deteriorated further, resulting in critical laboratory findings and the need for emergency transfer to the hospital, where the resident was diagnosed with hypoglycemia, hyperkalemia, acute renal failure, septic shock, and respiratory failure. The delay in recognizing and responding to the resident's acute change in condition, as well as the failure to follow established care protocols and physician orders, directly contributed to the deficiency identified by surveyors.