Failure to Timely Assess Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to assess a resident's change of condition in a timely manner. The resident, who had end stage kidney disease and diabetes and was admitted with moderate cognitive impairment, was observed by multiple staff to be lethargic, difficult to rouse, and unable to take medications. Despite these observations and repeated reports from a CMA and CNA to the charge nurse, there was no documented evidence that a physical assessment, vital signs, or blood sugar checks were performed, nor was the on-call provider contacted. The only recorded vital sign was a blood pressure reading several hours after the initial concern, and the resident was ultimately sent to the hospital at the family's request. Interviews with staff confirmed that the expected protocol for a change in mental status—such as immediate assessment, obtaining vital signs, checking blood sugar, and notifying the provider—was not followed. The nurse responsible did not document any assessment or communication with the provider, and the on-call provider confirmed they were not notified. The resident was later found to have sepsis due to a urinary tract infection upon hospital admission. Facility leadership acknowledged the lack of assessment and documentation in this incident.