Failure to Address Change in Condition and Document Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that changes in condition for two residents were thoroughly addressed and that vital signs and physician-ordered assessments were obtained and documented as required. For one resident with severe cognitive impairment and multiple diagnoses, including malnutrition and dementia, staff identified vomiting and notified the nurse practitioner, who ordered STAT labs and imaging. However, the required laboratory tests and stool sample were never obtained, and vital signs were not fully documented in the medical record. Multiple LPNs confirmed that the change in condition was not fully addressed, and documentation of assessments and interventions was lacking. For another resident with a history of congestive heart failure, hypertension, and respiratory failure, there was a physician's order for vital signs to be taken every four hours. Review of the Treatment Administration Record showed that nurses signed off that vitals were obtained, but there was no documentation of the specific vital signs as ordered. Electronic monitoring records showed sporadic documentation of pulse, respiration, temperature, and blood pressure, but not consistently at the required intervals, and not all parameters were recorded as ordered. Interviews with nursing staff and the Director of Nursing confirmed that the required assessments and documentation were not completed according to physician orders and facility policy. The facility's policy required thorough assessment and documentation of changes in condition, including vital signs and communication with the physician, but these steps were not consistently followed for the residents reviewed.