Failure to Assess and Notify Change in Condition Resulting in Delayed Hospitalization
Penalty
Summary
The facility failed to properly assess a resident who experienced a change in condition, specifically regarding symptoms of nausea, vomiting, and decreased oral intake. The resident, who had a history of dementia, chronic kidney disease, and congestive heart failure, was observed by staff and family to be unusually lethargic and to have episodes of vomiting over several days. Despite these symptoms, nursing staff did not perform a thorough assessment, such as checking the resident's abdomen for bowel sounds or distention, nor did they document the time of the last bowel movement. Communication among staff was inconsistent, with some staff unaware of the resident's gastrointestinal issues, and there was a lack of prompt notification to the physician regarding the resident's change in condition. Additionally, the facility did not notify the resident's physician or representative in a timely manner as required by policy when the resident's condition changed. The delay in assessment and notification resulted in the resident being hospitalized with a diagnosis of small bowel obstruction, dehydration, and other complications, requiring nasogastric decompression and multiple attempts at intravenous access for fluid resuscitation. The facility lacked a specific policy for gastrointestinal assessment, and staff interviews revealed gaps in communication and follow-through on reporting and assessing significant changes in the resident's health status.