Delayed Response to Stroke Symptoms and Failure to Discontinue Mid-Line Catheter
Penalty
Summary
A facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a stroke, including slurred speech, altered mental status, and fatigue. The resident's family member reported these symptoms to nursing staff on a Sunday, but the nurse on duty did not document the complaint, did not notify the provider or facility administration, and did not communicate the events to the night shift nurse. The nurse attributed the symptoms to possible early dementia and suggested a psychiatric consultation for the following day, without performing or documenting a thorough assessment or following the facility's change in condition protocol. The following day, another nurse was notified of the family’s concerns and performed an assessment, noting decreased cognition and slower speech. The nurse then notified the nurse practitioner, who ordered laboratory tests and, after discussion with the family, arranged for the resident to be transferred to the hospital for further evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic infarct (stroke) and experienced a significant decline in activities of daily living, requiring substantial assistance for mobility and care. Interviews with facility staff and review of records confirmed that the initial report of stroke symptoms was not acted upon for over 24 hours, and required notifications and documentation were not completed as per facility policy. Additionally, the facility failed to obtain a timely physician order to discontinue a mid-line catheter for another resident after completion of IV antibiotic therapy, resulting in the device remaining in place for an extended period without medical necessity. These failures were identified through observation, interviews, and record review, and were found to be inconsistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.