Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to follow its policy and perform a timely assessment on a resident who exhibited a change in condition. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, chronic kidney disease, and morbid obesity, was noted to be lethargic and required oxygen after a drop in oxygen saturation. Nursing staff did not complete or document a thorough assessment, including vital signs and neurological status, when the resident's condition changed. The nurse on duty did not seek assistance from other nurses, did not call an internal code, and only called 911 after the resident became barely responsive. Documentation of vital signs and the use of oxygen was incomplete, with the last recorded vital signs taken hours before the emergency transfer and delayed progress notes regarding oxygen administration. The facility's policy required staff to assess and document vital signs, neurological status, and changes in level of consciousness when a resident experiences an acute change in condition. Staff were also expected to notify the physician and monitor the resident's progress. In this case, the nurse did not collect or report the necessary information to the physician, and there was a lack of monitoring and documentation as required by facility policy. The resident was ultimately transferred to the hospital, where they were diagnosed with hypothermia, septic shock, thrombocytopenia, and hypernatremia.