Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies in assessing, monitoring, and recognizing clinical changes in a resident who experienced ongoing clinical decline. The resident, an elderly female, was admitted with multiple health concerns including a dental infection, use of a diuretic for congestive heart failure, and was at risk for weight loss. Over the course of her stay, she developed recurrent vomiting, hypotension, altered mental status, and ultimately required hospitalization for aspiration pneumonia, severe hyperkalemia, acute renal failure, and sepsis. Staff interviews and record reviews revealed that changes in the resident’s condition, such as increased confusion, falls, and weakness, were not consistently documented or communicated among the care team. Daily skilled nursing assessments were not completed as required, and there was a lack of clear documentation regarding the onset and progression of the resident’s decline. Further review showed that vital signs, intake and output, and weights were not consistently recorded in the medical record, despite physician orders and facility policies requiring such documentation. The resident experienced a significant, unmonitored weight loss and there was no evidence that the dietitian or physician was notified of her declining intake. Staff members reported that they relied on their own assessment and critical thinking skills due to the absence of clinical pathways, and that training on assessment skills was primarily delivered through computer modules or infrequent staff meetings. Additionally, the facility’s electronic health record system had issues with hydration tracking, and some documentation was deleted or not entered, further impeding the ability to monitor the resident’s status. The facility’s policies required accurate, complete, and timely documentation of assessments, observations, and services provided, as well as systematic approaches to optimize hydration status. However, these protocols were not followed for this resident. Staff interviews confirmed that documentation of the resident’s change in condition, interventions, and communication with providers was lacking or missing entirely. The failure to document and respond appropriately to the resident’s clinical changes resulted in her developing severe complications and requiring hospitalization.