Failure to Recognize and Respond to Change in Condition and Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice, specifically related to pain management, recognition of a change in condition, and timely action. The resident, who had diagnoses including heart failure, diabetes, anxiety, and lymphedema, experienced increased pain and difficulty breathing. Despite complaints and observable distress, staff did not consistently assess, document, or communicate the resident's changing condition to the appropriate medical providers in a timely manner. Orders from a nurse practitioner for additional pain management and oxygen weaning were not transcribed into the medical record until many hours after being received, and there was a lack of thorough documentation regarding the resident's assessments and interventions throughout the day. Multiple staff interviews and record reviews revealed that the resident exhibited significant pain and respiratory distress throughout the day, including crying out during care and expressing ongoing discomfort. Certified nursing assistants and nurses noted the resident's unusual pain and lethargy, but there were gaps in communication and follow-up. Pain assessments were not consistently performed or documented, and vital signs were not always recorded. The resident's requests for pain relief and reports of difficulty breathing were not adequately addressed, and there was a delay in notifying the nurse practitioner or physician about the resident's deteriorating condition. The resident ultimately requested to be sent to the emergency room, where they were diagnosed with sepsis, right pleural effusion, and acute renal failure, and subsequently admitted to the intensive care unit. The facility's failure to recognize and act upon the resident's change in condition, complete thorough assessments, and provide timely care resulted in serious harm. Staff did not follow the facility's policies on pain management and notification of changes, nor did they adhere to the nursing process as required by professional standards. The lack of timely transcription of orders, incomplete documentation, and insufficient communication among staff contributed to the deficient practice.
Removal Plan
- Complete head-to-toe assessment for all in-house residents.
- Implement eInteract Point Click Care (PCC) Evaluation for Change in Condition and use of internet tools and resources.
- Review in-house residents in Interdisciplinary Team (IDT) meetings for completion, documentation, and identification of a change in condition, assessments (including vital signs), and provider notification.
- Educate staff on the facility's policies regarding notification, pain management, identifying a change in condition, and transcription and documentation of orders.
- Implement audits and review progress notes for change of condition response.