Failure to Identify and Intervene in Acute Change of Condition Following Stroke
Penalty
Summary
Facility staff failed to identify and appropriately intervene in an acute change in condition for a resident who had recently suffered multiple strokes and was admitted for rehabilitation. The resident's care plan did not address the recent stroke or include standard interventions for stroke patients, such as elevating the head of the bed to prevent aspiration. Staff did not recognize the resident's occasional moist cough during meals as a potential early sign of aspiration, nor did they communicate this symptom to the physician. Documentation was inconsistent, with conflicting information about the resident's distress when positioned on his back, and the care plan lacked necessary interventions for aspiration prevention. On the evening of admission, the resident developed an increased moist cough and audible congestion, with oxygen saturation dropping to 78%. Staff performed suctioning and notified the physician, who ordered Duoneb and Robitussin for cough and respiratory symptoms. However, staff did not administer these medications as ordered. Progress notes included late entries after the resident was discharged, and there was a lack of timely and accurate communication among staff and with the physician regarding the resident's symptoms and response to interventions. The family was not kept adequately informed of the resident's deteriorating condition and ultimately had to request hospital transfer after observing significant respiratory distress the following morning. Interviews with nursing staff revealed gaps in hand-off communication and a lack of prompt action in response to the resident's low oxygen saturation and persistent symptoms. The physician was not informed that the resident's cough occurred during oral intake, which may have influenced the care plan. The Director of Nursing confirmed that the care plan should have addressed the resident's stroke diagnosis to prevent aspiration. As a result of these deficiencies, the resident was admitted to the hospital in respiratory distress due to aspiration and subsequently placed on hospice care.