Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition in a timely manner for a resident with multiple complex diagnoses, including multiple sclerosis, adult failure to thrive, a history of urinary tract infections, cystic liver disease, dysphagia, and abnormal weight loss. The resident was noted by a CNA to have decreased appetite and changes in behavior over several days, including being less responsive and not exhibiting her usual complaints during care. Despite these observations, the CNA's concerns were not promptly acted upon by nursing staff, and no documented assessments or vital signs were recorded during the period when the resident's condition was changing. On the day of the incident, both the CNA and the LPN observed that the resident was more tired than usual and not at her baseline. The LPN attributed the resident's fatigue to possible poor sleep and did not perform an assessment or obtain vital signs. The unit manager and the DON were also made aware of the resident's change in condition, but again, no assessment or vital signs were documented. The family was notified and requested a urinalysis, which was ordered, but staff were unable to obtain a sample. Later in the day, the resident was found to be unresponsive and hot to the touch, at which point she was sent to the hospital and subsequently admitted for sepsis and dehydration. The facility's documentation revealed a lack of timely and thorough assessment following reports of a change in condition, as well as gaps in monitoring and documentation of the resident's nutritional status and weight trends. The care plan for the resident included interventions for monitoring for signs of malnutrition, dehydration, and infection, but these were not effectively implemented. Facility policies and job descriptions require prompt assessment and documentation of changes in condition, but these were not followed in this case, resulting in a failure to provide necessary care and monitoring.