Failure to Assess and Document Change in Condition for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to properly assess a resident for a change in condition, specifically neglecting to perform and document daily assessments and vital signs as required for a Medicare skilled stay. The resident, who had multiple complex diagnoses including a surgically repaired right leg trimalleolar fracture, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure, was admitted from an acute care hospital and later discharged back to a hospital. Documentation revealed that the resident experienced significant weight gain (11.4 pounds in ten days), edema in both legs, and a weak pulse in the right foot, but there was no evidence that these changes were communicated to the medical provider or that appropriate assessments were performed and recorded daily. Review of the resident's progress notes and vital signs showed inconsistent and incomplete documentation. Several nursing and Medicare notes failed to address key aspects of the resident's condition, such as edema, neurovascular status of the right foot, and the presence or condition of the cast or splint. The facility's own policy required daily documentation for skilled Medicare residents, including full assessments and vital signs, but this was not consistently done. The resident's weight record indicated a notable increase, yet there was no documentation of provider notification regarding this change. Interviews with facility staff, including a registered nurse, resident care manager, provisional administrator, and director of nursing, confirmed that the required daily assessments and documentation were not present in the electronic health record. Staff acknowledged that, given the resident's diagnoses, assessments should have included respiratory status, oxygen saturation, edema, and neurovascular checks of the right foot at least daily, but these were not documented. The deficiency was identified through record review and staff interviews, which verified the lack of appropriate assessment and documentation for the resident's change in condition.