Failure to Identify and Respond to Changes in Resident Condition and Incomplete Post-Fall Assessments
Penalty
Summary
The facility failed to identify and respond appropriately to significant changes in behavior and mental status for two residents, resulting in delayed medical intervention and treatment. In one case, a resident with a history of metabolic encephalopathy, stroke, and dysphagia exhibited new behaviors including undressing, increased confusion, and agitation. Despite these changes being reported by both staff and a family member, nursing staff did not conduct thorough ongoing assessments or notify medical staff of the changes. The family member expressed concern and requested that 911 be called, but the nurse declined, stating that staff would handle the situation. The resident was later found on the floor, naked and confused, by the family, who then called EMS. Upon hospital admission, the resident was diagnosed with acute encephalopathy, acute respiratory failure, hypotension, lactic acidosis, acute kidney injury, transaminitis, septic shock, and aspiration pneumonia, requiring intensive care and ventilator support. In another case, a resident with severe cognitive impairment and a history of metabolic encephalopathy and dementia experienced two falls in one day. After the first unwitnessed fall, neurological checks and vital signs were initiated, but a low pulse rate was documented twice and not reported to the nurse practitioner. The nurse practitioner, who assessed the resident after the first fall, was not made aware of the abnormal vital signs. Following a second fall, neurological checks were again initiated, but documentation errors occurred, and witness statements were not obtained. The responsible party reported a lack of monitoring and observed a head injury that was not initially documented by staff. Interviews with staff revealed gaps in communication, documentation, and adherence to protocols for monitoring and reporting changes in residents' conditions. Nursing staff did not consistently recognize or escalate significant changes in behavior or vital signs to medical providers, and there was a lack of thorough ongoing assessment following incidents such as falls or changes in mental status. These deficiencies resulted in delayed medical evaluation and treatment for the affected residents.