Failure to Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for a resident who experienced a change in condition. Specifically, after the resident was observed to have poor oral intake and low blood pressure, there was no documented evidence that the resident's condition was monitored every shift for at least 72 hours as required. Medical record review showed gaps in monitoring during three consecutive shifts following the initial change in condition. Interviews with nursing staff confirmed that the resident's medical record did not contain documentation of shift-by-shift monitoring after the change in condition was identified. Staff acknowledged that residents with a change in condition should be monitored every shift for a minimum of 72 hours, and that this monitoring should be documented in the medical record. The lack of documentation indicated that the required monitoring was not performed or recorded as per facility protocol.