Failure to Address Abnormal Lab Result and Monitor NPO Resident After Oral Intake
Penalty
Summary
The facility failed to address an abnormal laboratory result and did not monitor a resident for signs of aspiration following an incident that may have required physician intervention. Specifically, a resident with a history of difficulty swallowing and who was on an NPO (nothing by mouth) diet was found with a grape ice pop in their hand and a large piece in their mouth. Despite this, there was no documentation of a change in the resident's condition or initiation of monitoring for aspiration. Additionally, the resident's medical record showed an abnormally high white blood cell (WBC) count, which is significant for identifying infection or inflammation, but the facility did not document any response to this abnormal result or a change in the resident's condition. The lack of documentation and monitoring occurred despite the resident's known risk factors and the presence of clinical indicators that warranted further assessment.