Failure to Recognize and Respond to Change in Condition
Penalty
Summary
Nursing staff failed to recognize and appropriately act on a significant clinical change in condition for a resident with multiple complex medical diagnoses, including hemiplegia, hemiparesis, cerebral infarction, dysphagia, and diabetes mellitus. The resident exhibited abnormal laboratory results, specifically an elevated white blood cell count and blood urea nitrogen, which were not communicated to the physician as required by facility policy. Additionally, daily resident assessments were not completed on two consecutive days, which could have detected early signs of decline. On subsequent days, the resident presented with low blood pressure and elevated heart rate, yet these abnormal vital signs were not reported to the physician. The resident's condition further deteriorated, with altered mental status, increased weakness, decreased communication, shortness of breath, and distress, accompanied by a critically low oxygen saturation. Despite these significant changes, nursing staff did not promptly notify the physician or take appropriate action until the resident's family member intervened and insisted on emergency medical attention. The lack of timely assessment, failure to report abnormal findings, and inadequate response to the resident's clinical decline resulted in the resident being transferred to an acute care hospital, where she was diagnosed with sepsis and acute kidney injury, requiring intensive care. Interviews and record reviews confirmed that staff did not follow facility protocols for assessment, notification, and escalation of care in response to abnormal findings and changes in the resident's condition.