Failure to Report and Investigate Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a change in a resident's condition was reported and properly investigated. A resident with multiple diagnoses, including end stage renal disease, was noted in progress notes to have new skin discoloration on the face and hand, and subsequently on the left eye and nose over several days. Despite these documented changes, nursing staff did not report the new skin discoloration to the charge nurse, and no investigation into the cause of the discoloration was initiated by the facility. Interviews with facility staff confirmed that nurses are expected to report any change in a resident's condition to the charge nurse for further investigation, as outlined in the facility's policy on unusual occurrence reporting. However, the responsible LVN admitted to not reporting the discoloration, and the Minimum Data Set Coordinator confirmed that no investigation was conducted. This failure to follow reporting and investigation procedures resulted in the deficiency.