Failure to Timely Assess and Intervene After Acute Change in Condition Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and provide comprehensive, resident-centered interventions following an acute change in condition for a resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, dementia, and a history of weight loss. The resident, who required staff assistance with activities of daily living, was observed by staff to have an acute change in medical condition, including dusky colored hands and feet, limited food and fluid intake, lethargy, and the need for supplemental oxygen. Despite these significant changes, there was no documented assessment or intervention by licensed staff at the time these symptoms were first noted. Over the course of several days, the resident's condition continued to deteriorate, with ongoing poor oral intake and increasing lethargy. Multiple staff members, including CNAs, reported the resident's declining condition and abnormal physical findings to various nurses, but there was no evidence that a comprehensive assessment was performed or that the resident's medical provider was notified in a timely manner. Documentation was lacking regarding the resident's status, interventions provided, and physician notifications. The resident's care plan did not address hydration risk or the need for assistance with food and fluid intake, despite ongoing weight loss and poor appetite. The failure to assess and respond to the resident's change in condition resulted in a significant delay in medical intervention. The resident was ultimately transferred to the hospital only after a licensed nurse, returning from time off, discovered the resident in a severely compromised state. At the hospital, the resident was diagnosed with severe dehydration, acute kidney injury, and malnutrition, and subsequently passed away after being transferred to hospice care. The deficiency was identified through closed medical record review, interviews, and review of facility policies and procedures.
Removal Plan
- Resident #95 was transferred to the hospital and did not return to the facility. The resident expired.
- An audit was completed by DON/Designee on all residents who went out to the hospital to determine if any changes in resident conditions went unreported.
- The President of Clinical Operations reviewed the following policies and procedures to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse.
- The Regional Director of Clinical Services, Regional Director of Operations and Administrator initiated education for all licensed staff on Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse Policy. Education was completed for Licensed Practical Nurses (LPNs), Registered Nurses (RN), Certified Nurse Aides (CNAs), Activity Personnel, Dietary Staff, Housekeeping/Laundry Staff, Maintenance Staff, Administrative Staff. All staff were educated.
- The DON/Designee provided education for nursing staff on the POC alert function in Point Click Care (PCC) charting to identify potential condition changes and how alerts generate on the alert panel on PCC dashboard. Education was completed for Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Certified Nurse Aides (CNAs). This was provided in person and via phone before staff were allowed to work. Education included how alerts appear on the dashboard and are reviewed daily in morning clinical meetings. If reported changes were not addressed by the nurse, they were to report it to the DON. Education also included ongoing changes in conditions would be reported to the DON.
- The DON/Designee educated in person and via phone Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the Change in Condition policy, which included when a change of condition was reported, new orders were obtained, entered in PCC/implemented, which would include appropriate monitoring, including oxygen therapy needs.
- Ongoing compliance would include new nurses in orientation upon hire.
- The Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Services, Social Services, Minimum Data Set (MDS) Nurse, Human Resources, Director of Nursing (DON), Activities Director, Assistant DON (ADON)/LPN, and Medical Director reviewed the facility plan of action, the policies and procedures related to Change in Condition and Notification and a root cause analysis was completed.
- A whole house audit was conducted on all current facility residents by the DON/Designee by reviewing 72-hour report for any change of condition and need for interventions and notifications and head to toe assessments by DON/Designee.
- The facility began audits on resident change in condition by reviewing the 24 hour and 72-hour reports which would be reviewed five times per week ongoing by DON/Designee. Audits would include Change in Condition and Notification. If adverse findings were noted, an immediate head to toe assessment would be completed and notification to physician.
- All findings would be reviewed weekly in QAPI. The Administrator and the DON would be responsible for the oversight of the monitoring/audits.
- Director of Nursing/Designee conducted an audit on all orders placed, including medications, treatments, monitoring, therapy, etc. for all residents. This audit concluded that all orders were appropriate, contained no errors, and provided necessary monitoring where needed.