Failure to Promptly Transfer Resident with Sepsis Symptoms
Penalty
Summary
A facility failed to follow its own guidelines for the prompt transfer of a resident exhibiting signs and symptoms of sepsis, resulting in a delay of approximately six hours before the resident was sent to the hospital. The resident, who had a complex medical history including cerebral neoplasm, seizures, spastic hemiplegia, encephalopathy, diabetes, and a history of sepsis, began showing abnormal vital signs and symptoms such as hypoxia, tachycardia, low blood pressure, and altered mental status. Multiple staff members, including a speech therapist and registered nurse, noted these changes and communicated them to the nurse practitioner, who ordered diagnostic tests and treatments but did not assess the resident's vital signs during their visit or address the abnormal findings reported by nursing staff. Despite the facility's policy requiring sepsis screening and prompt action when two or more SIRS criteria are met, no formal sepsis screening was completed, and key laboratory tests such as blood cultures, CMP, coagulation tests, and lactate were not ordered or drawn as required. The resident's family expressed concern and requested hospital transfer, citing a history of sepsis, but the transfer was not initiated until later that evening after further deterioration and abnormal lab results were noted. Documentation and interviews revealed that staff were aware of the resident's change in condition and the potential for sepsis but did not follow the facility's sepsis care guidelines, which call for immediate physician notification, IV fluids, and consideration for hospital transfer unless specific exceptions apply. The delay in recognizing and responding to the resident's sepsis symptoms resulted in the resident being hospitalized and diagnosed with septic shock and pneumonia. Interviews with staff, including the DON, nurse practitioner, and medical director, confirmed that the facility was not equipped to treat sepsis in-house and that the established protocol was not followed. The facility's failure to implement its sepsis guidelines and promptly transfer the resident for higher-level care constituted a deficiency in quality of care.