Failure to Timely Transfer and Monitor Resident with Acute Change in Condition
Penalty
Summary
A resident with a complex medical history, including gram-negative sepsis, heart failure, and dependence on supplemental oxygen, experienced an acute change in condition that was not promptly recognized or addressed by facility staff. The resident became unresponsive, diaphoretic, and exhibited labored breathing with a high fever and abnormal urine characteristics. Despite these significant changes, there was a delay in transferring the resident to the hospital, and staff failed to provide timely and thorough assessments or interventions during the acute episode. Documentation and interviews revealed that staff did not consistently monitor or document the resident's vital signs or Foley catheter status. The care plan and Kardex lacked specific interventions for ongoing assessment and monitoring of the Foley catheter, and staff were unclear on how to track urine output for residents with catheters. CNA and nursing documentation indicated that only one set of vital signs was recorded during the critical period, and there was no evidence of further nursing care or assessment until EMS arrived. Upon EMS arrival, the resident was found to be in severe distress, with a temperature of 104.1°F, unresponsiveness, and significant respiratory compromise, requiring intubation shortly after arrival at the emergency room. Interviews with facility leadership and staff highlighted gaps in communication, documentation, and escalation of care. Concerns raised by the resident's family regarding decreased mobility and responsiveness were not thoroughly assessed or communicated to the appropriate staff. The lack of clear protocols for monitoring residents with Foley catheters and the absence of timely nursing interventions contributed to the delay in recognizing the severity of the resident's condition and transferring him to the hospital.