Failure to Monitor Residents After Change of Condition
Penalty
Summary
Licensed nurses failed to follow professional standards of practice by not monitoring three residents after each experienced a change of condition (COC). For one resident with end stage renal disease, type 2 diabetes mellitus, and COPD, there was no documented evidence of respiratory monitoring for two consecutive shifts following episodes of shortness of breath. Both the registered nurse and interim director of nursing confirmed that monitoring was not completed as required, and acknowledged that the resident's respiratory status was not assessed every shift for 72 hours after the COC. Another resident, admitted with pleural effusion, asthma, and chronic respiratory failure, experienced shortness of breath and was not monitored on several shifts following the COC. Documentation was missing for specific shifts, and both the registered nurse and interim director of nursing confirmed that the resident was not monitored every shift for 72 hours as per protocol. The lack of monitoring was acknowledged as a failure to assess the effectiveness of interventions and to detect any worsening of the resident's respiratory condition. A third resident, with a history of diabetes, foot ulcer, and gastro-esophageal reflux disease, had a COC involving nausea, multiple episodes of vomiting, and abdominal pain. There was no documented monitoring for one shift after the COC, and both the registered nurse and interim director of nursing confirmed the lapse. Facility policy required monitoring and documentation of residents' progress and responses to treatment after a COC, but this was not followed for these residents.