Failure to Assess, Monitor, and Communicate Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the Wisconsin Nurse Practice Act for a resident who experienced a significant change in condition. The resident, who had a history of diabetes mellitus, Parkinson's disease, and severe cognitive impairment, became increasingly lethargic, refused food, had a small emesis, and had not had a bowel movement for three days. Despite these changes, there was no documentation of a nursing assessment, including vital signs, at the time of the change in condition. Additionally, there was no documentation of the emesis, administration or results of medication for constipation, or the administration and results of a COVID-19 test, even though these were referenced in a nurse practitioner's note. Laboratory work was ordered and collected, and results showed a critically elevated white blood cell count, which was reported to the facility late in the evening. However, there was no evidence that facility nursing staff acknowledged receipt of these results, notified the nurse practitioner or physician, or monitored the resident for further decline. Interviews with staff revealed a lack of communication between shifts regarding the resident's change in condition and pending laboratory results. Staff on subsequent shifts were unaware of the resident's status or the need for close monitoring, and no vital signs or assessments were documented after the initial change in condition. On the following day, the resident was found to be in severe distress, with altered mental status and respiratory difficulty, and was transferred to the hospital by EMS. Hospital records confirmed diagnoses of septic shock due to a urinary tract infection, acute hypoxic respiratory failure, and cardiogenic shock. There was no documentation in the facility's records prior to transfer explaining the circumstances leading to the emergency call or the resident's deteriorating condition. The lack of assessment, monitoring, documentation, and communication among staff directly contributed to the failure to provide care according to professional standards and the resident's comprehensive assessment.