Failure to Ensure RN Assessment After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a registered nurse (RN) assessed a resident following a significant change in condition. According to the Pennsylvania Nursing Practice Act and the facility's own policies, an RN is required to assess residents after a change in condition, particularly when there is new or worsening pain. In this case, a resident who was cognitively intact and required assistance with daily care experienced severe, uncontrolled pain that was not relieved by scheduled Tylenol. The resident cried out in pain when moved, expressed distress, and verbalized a desire to die due to the pain. Documentation showed that an LPN noted the resident's pain and communicated with the physician regarding comfort care, stronger pain medication, or hospice, but there was no evidence that an RN assessed the resident during this episode. The Director of Nursing confirmed that there was no documented RN assessment at the time of the resident's pain episode, despite facility policy and state regulations requiring such an assessment. The lack of RN assessment and documentation following the resident's significant change in condition constituted a failure to meet professional standards of quality and the facility's own protocols for pain management and change in condition.