Failure to Timely Assess and Treat Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including type 2 diabetes, chronic kidney disease, chronic pancreatitis, depression, and muscle weakness, experienced a significant change in condition that was not promptly assessed or addressed by nursing staff. On the evening in question, a CNA observed the resident doubled over in pain, grayish in color, and vomiting, with a fever of 103°F and a self-reported pain level of 10 out of 10. The CNA reported the resident's condition to the nurse on duty, but the nurse did not assess or provide medical care for approximately two hours after the initial notification. During this time, the resident continued to deteriorate, and multiple staff and residents reported the resident's distress to the nurse, but no timely intervention occurred. The resident's condition escalated to the point where the CNA, after observing continued vomiting and severe pain, called 911 from her personal phone. Emergency medical services arrived and transported the resident to the hospital, where he was diagnosed with fever, a left heel wound infection, a complicated urinary tract infection (UTI), and acute kidney injury (AKI). Interviews with staff and residents revealed inconsistent accounts regarding the communication of the resident's symptoms to the nurse, but it was confirmed that the nurse did not enter the resident's room or assess him until emergency services had already been called and were arriving at the facility. Documentation and interviews further indicated that the nurse did not notify the resident's family or responsible party of the hospitalization, and there was a lack of clear, timely communication and follow-up regarding the resident's change in condition. The facility's own policies required prompt assessment and notification of significant changes in a resident's health status, but these procedures were not followed in this instance, resulting in a delay in care and failure to provide treatment in accordance with professional standards of practice.