Failure to Assess and Document Change in Condition Leading to Hospitalization
Penalty
Summary
A resident with multiple chronic conditions, including hypertension, chronic Foley catheter use, and a history of urinary retention, did not receive assessment, treatment, and care in accordance with professional standards of practice following a change in condition. The resident experienced increased pain, rated at 8 out of 10, and received PRN Oxycodone during the night shift for the first time at this pain level. Despite physician orders requiring daily vital signs due to hypertension and specific documentation of pain characteristics with each PRN pain medication administration, there was no documented assessment of the cause of pain, vital signs, or pain characteristics at the time of administration. The medication administration record was blank for the required pain flow sheet documentation, and vital signs were not recorded as ordered, with the last documented set occurring nearly two weeks prior to the incident. Certified Nursing Assistants (CNAs) and nursing staff observed and reported that the resident was not feeling well, appeared unwell, and had no urine output in the urinary collection bag on the morning of the incident. The resident reported symptoms such as a hard abdomen and foul-smelling urine to both CNAs and nursing staff, but these concerns were not adequately assessed or documented. Interviews revealed that staff either did not recall or did not perform a full assessment, and there was no evidence of a comprehensive evaluation or documentation of the resident's change in condition prior to the resident being sent to a scheduled medical appointment. The facility's policy required baseline assessments and documentation for acute changes in condition, which were not followed. Upon arrival at the physician's office, the resident was found to have an empty urinary collection bag and was subsequently transferred to the emergency department, where he was diagnosed with sepsis, acute renal failure, and septic shock due to urinary obstruction from a clogged Foley catheter. Hospital records confirmed that the resident had experienced lower abdominal pain and lack of urine output for at least two days prior to admission. The lack of timely assessment, documentation, and intervention by facility staff in response to the resident's change in condition and physician orders led to a significant health decline requiring ICU admission.