Failure to Initiate Change in Condition for Abnormal Lab Result
Penalty
Summary
The facility failed to complete a required change in condition (COC) for a resident who exhibited a sudden and clinically significant deviation from baseline health status. The resident, who had a history of cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia, was found to have an elevated uric acid level of 10.3 mg/dl, which was above the normal range. Additionally, the resident presented with swelling, tenderness, and pain in the left third finger. Although the physician was notified and further diagnostic tests were ordered, the facility did not initiate a COC as required by their policy. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a COC should have been completed to ensure appropriate monitoring and communication among staff regarding the resident's abnormal lab result and change in condition. Review of facility policy indicated that prompt notification and documentation of changes in a resident's medical or mental condition are required, but this process was not followed in this instance.