Failure to Document and Respond to Resident's High Temperature
Penalty
Summary
Nursing staff failed to document physician notification, a change in condition, nursing interventions, or attempts to obtain a physician order to manage a resident's high temperature, as required by facility policy. The resident, who had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pneumonia, was admitted with these diagnoses. On the evening of 08/14/2025, the resident's oral temperature was recorded at 102.9°F, but there was no further temperature documented until the following afternoon, over 15 hours later. During this period, there was no documentation of any interventions, physician or family notification, or a change in condition assessment in the medical record. Interviews with nursing staff, including LPNs, CNAs, an RN, and the DON, revealed that the facility's standard practice was to consider a temperature above 100.3°F as high and to implement interventions such as cooling measures, hydration, and notifying the physician for further orders, including medication like Tylenol. Staff also indicated that a change in condition assessment would be completed, the physician and family would be notified, and the temperature would be rechecked within an hour. However, in this case, none of these actions were documented for the resident with the high temperature. A review of the facility's policy on changes in a resident's condition confirmed that prompt notification of the physician, resident, and representative was required, along with detailed documentation of observations and interventions. The DON and physician both confirmed that the medical record lacked evidence of a change in condition, nursing interventions, or physician notification related to the resident's high temperature. The absence of documentation and follow-up actions was inconsistent with both facility policy and staff statements regarding standard procedures.