Failure to Monitor and Report Changes in Condition for Two Residents
Penalty
Summary
The facility failed to monitor and report significant changes in condition for two residents, including not consistently tracking and reporting blood pressures, daily weights, and urination as required by physician orders and facility policy. For one resident, who had a history of heart failure, kidney disease, and recent hospitalization, there was a lack of routine documentation and provider notification regarding low urine output, low blood pressures, and weight gain. Despite orders to notify the provider for specific changes, such as no urinary output for eight hours or significant weight gain, these were not reported in a timely manner. Attempts to collect urine samples were unsuccessful over several days, and there was no documentation that the provider was notified of these failed attempts or of the resident's ongoing symptoms and abnormal findings until the resident's condition had significantly deteriorated. The resident subsequently experienced a series of acute medical events, including hyponatremia, acute kidney injury, renal failure, urinary tract infection, and required hospitalization and dialysis. Documentation shows that the resident and family had expressed concerns about urine output and fluids to staff, but these concerns were not adequately addressed or communicated to the provider. Staff interviews revealed confusion about when to escalate care, how to document and report changes, and how to follow up on orders, particularly over weekends when laboratory services were limited and there was no nurse manager present to ensure continuity of care. A second resident, also with a history of heart failure and recent hospitalizations, did not have daily weights or vital signs resumed or documented after readmission from the hospital, despite clear orders to do so. The lack of monitoring and documentation was confirmed by facility leadership, who cited issues with order entry and access to provider notes in the electronic medical record. These failures resulted in delays in recognizing and responding to changes in condition for both residents, as evidenced by the lack of timely provider notification and incomplete monitoring as required by policy and physician orders.