Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide appropriate assessment and care for a resident who exhibited a significant change in condition. The resident, who had a history of Parkinson's disease, anemia, hyponatremia, chronic kidney disease, congestive heart failure, and hypertension, was noted by staff and family to be less responsive, exhibiting increased shaking, drooling, and difficulty swallowing. Despite these changes, the RN did not perform a comprehensive assessment, did not obtain vital signs, and did not provide a detailed report to the physician. The only action taken was to verbally notify the Director of Nursing (DON) and request that the physician look at the resident, which resulted in lab work being ordered for the following day. There was no documentation of a thorough assessment or timely communication of the resident's deteriorating condition to the physician. Throughout the day, the resident's condition continued to decline. Certified Nursing Assistants (CNAs) and other nursing staff observed that the resident was unable to eat or swallow, was minimally responsive, and required more assistance with transfers than usual. The second shift nurse, upon being informed of the resident's status, performed an assessment, obtained vital signs, and found the resident to have a low oxygen saturation. The resident was subsequently placed on supplemental oxygen and transferred to the emergency department, where he was found to be unresponsive, hypothermic, dehydrated, and suffering from multiple abnormal lab values. The emergency department initiated aggressive warming and hydration measures, and the resident was admitted for comfort care. Interviews with facility staff confirmed that the RN on the day shift did not follow professional standards of practice as outlined in the Wisconsin Nurse Practice Act and facility expectations. The DON and physician both stated that the expectation was for the nurse to assess the resident, obtain vital signs, and communicate findings to the physician. The RN admitted to not completing an assessment or obtaining vital signs, and documentation was not completed in a timely manner. The facility was unable to provide a change in condition policy when requested by the surveyor.