Failure to Assess and Notify Provider After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely assessment and provider notification following multiple reports of a resident's change in condition over an 11-day period. The resident, who had diagnoses including dementia, gait abnormalities, and muscle weakness, was severely cognitively impaired and dependent on staff for most activities of daily living. After an unwitnessed fall, the resident exhibited increasing difficulty with mobility, pain in the left lower extremity, and an inability to bear weight, as documented by physical therapy staff. Despite these ongoing concerns, there was no evidence that nursing staff performed a comprehensive assessment or notified the provider of the resident's declining condition as required by facility policy. Physical therapy and occupational therapy staff repeatedly reported the resident's pain and functional decline to nursing staff and discussed these issues during morning and Medicare meetings. Documentation shows that therapy staff communicated changes in the resident's transfer status and mobility to the Director of Nursing (DON) through the interagency communication system. However, the DON did not review these communications and was not aware of the resident's change in condition until much later. Nursing notes during this period did not reflect any assessment or provider notification in response to the therapy staff's reports. Ultimately, the resident was found to have an acute left hip fracture after an x-ray was ordered following further decline and a new skin tear. Interviews confirmed that the DON and the provider were not notified of the resident's change in condition until the day the fracture was identified. Facility policy required that any change in condition be assessed by a licensed nurse and reported to the physician, but this process was not followed in this case.