Failure to Monitor and Treat Acute Medical Conditions Resulting in Hospitalization
Penalty
Summary
The facility failed to monitor and treat acute medical conditions for two residents, resulting in both requiring hospitalization. One resident with multiple chronic conditions, including COPD, congestive heart failure, and chronic respiratory failure, experienced severe respiratory distress during the night shift. The assigned nurse did not adequately assess or document the resident's deteriorating condition, failed to provide timely interventions, and did not properly record the administration of nebulizer treatments. The resident's oxygen saturation remained critically low until the day shift nurse intervened, at which point emergency services were called and the resident was hospitalized in the intensive care unit for respiratory failure, pneumonia, and other complications. Another resident with psychiatric and cardiac diagnoses, including schizophrenia, bipolar disorder, and congestive heart failure, exhibited severe anxiety, sweating, and difficulty breathing during the night shift. Although the medication administration record indicated that scheduled medications were given, the resident repeatedly stated that medications were not received, and staff observed ongoing distress. The nurse on duty did not provide adequate monitoring or intervention, and emergency services were called by the day shift nurse, resulting in the resident being sent to the hospital for evaluation. Multiple staff members, residents, and council notes documented ongoing concerns about the night shift nurse's failure to administer medications, perform treatments, and respond to residents' needs. Reports indicated that the nurse often did not complete medication passes, failed to document care appropriately, and was frequently unresponsive to requests for assistance. These actions and inactions directly contributed to the acute deterioration and subsequent hospitalization of the two residents.