Failure to Report Change in Condition Leads to Delayed Response and Resident Death
Penalty
Summary
A deficiency occurred when staff failed to report a resident's significant change in condition to nursing staff for timely assessment and intervention. The resident, who had a history of anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status, was noted by two CNAs to have dilated pupils, cool skin, decreased responsiveness, and increased muscle stiffness during care. Despite these notable changes from the resident's baseline, neither CNA informed the nurse on duty about the observations. Approximately 15-20 minutes after the initial observations, one of the CNAs returned to check on the resident and found the individual unresponsive. The CNA then notified the nurse, who arrived after a short delay, and CPR was initiated. Multiple staff members, including a paramedic and other CNAs, later confirmed that the resident was cold to the touch and already stiffening during resuscitation efforts, indicating a significant lapse in timely recognition and response to the change in condition. Interviews with staff, including the DON and Medical Director, confirmed that facility policy requires staff to report any change in a resident's condition to a nurse, and if the assigned nurse is unavailable, to another available nurse. However, the CNAs involved did not communicate the observed changes, and the facility's policy did not specifically address communication protocols between nurse aides and licensed nursing staff. This failure to report and respond to the resident's change in condition resulted in a delay in assessment and intervention.
Removal Plan
- Clinical and agency staff were in-serviced on timely assessments
- Notification of Change Policy was reviewed
- QAPI meeting was held
- 24 hour reports were reviewed for change in condition