Failure to Obtain Vital Signs During Change in Condition Assessment
Penalty
Summary
The facility failed to complete a thorough assessment for a resident who experienced a change in condition. Specifically, when a resident with multiple diagnoses, including a lumbar vertebra fracture, clavicle fracture, rotator cuff tear, Alzheimer's disease, and osteoporosis, reported uncontrolled pain in the right foot, the nurse did not obtain a new set of vital signs at the time of the event. The last documented vital signs were taken three days prior to the change in condition. According to the facility's SBAR protocol, nurses are required to evaluate the resident, check vital signs, review the medical record, and have relevant information available before contacting the physician. Despite the resident's report of new, uncontrolled pain and the subsequent notification of the physician and family, the nurse did not follow the facility's policy to obtain and document current vital signs during the assessment. The Director of Nursing confirmed that no vital signs were taken at the time of the change in condition, and verified that the last set was recorded days earlier. This lapse was identified during a review of records, staff interviews, and policy review, and was cited as a deficiency under the facility's policy for notification of changes.