Failure to Assess, Notify, and Document Changes in Resident Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure the highest practicable well-being for a resident, as required by professional standards and the facility's own policies. Specifically, the facility did not complete follow-up assessments, notify the physician, or document actions taken when the resident exhibited a low pulse rate and poor oral intake. The resident's medical records showed multiple instances of bradycardia, with pulse rates below 60 bpm, and there was no evidence that these abnormal findings were followed up with appropriate clinical interventions or physician notification, as outlined in the facility's policy for changes in a resident's condition. Additionally, the resident experienced a significant decline in meal intake over several days, with documented refusals and consumption of less than 25% of meals on multiple occasions. Despite this, there was no documentation of follow-up assessments, physician notification, or care plan adjustments in response to the resident's poor nutritional intake. Interviews with nursing staff confirmed that these changes were observed and reported to charge nurses, but the required documentation and clinical follow-up were not completed. The Director of Nursing (DON) indicated that abnormal vital signs alone were not considered a significant change of condition and did not expect licensed nurses to document follow-up entries after providing interventions. The DON also stated that a significant change of condition related to meal intake would only be recognized after three to four days of consecutive low intake with refusal. These practices were inconsistent with the facility's policy and contributed to the failure to ensure timely and appropriate care for the resident.