Failure to Provide Timely Assessment and Care Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to provide care and services in accordance with a resident's care plan, preferences, and professional standards of practice. The resident, who had severe cognitive impairment, was totally dependent on staff for all activities of daily living, and required continuous tube feeding, routine hydration, and frequent monitoring, was not properly assessed or cared for during a specific shift. Staff did not perform required ADL care, repositioning, or timely assessments, and failed to recognize or respond to a change in the resident's condition. Documentation was inconsistent, with some staff noting the resident was 'not available' for care, while others admitted to not providing care or confusing the resident with another individual. During the shift in question, the assigned nurse administered medications via g-tube but did not physically assess the resident for responsiveness or breathing. The CNA assigned to the resident did not provide any ADL care, did not reposition the resident, and incorrectly documented the resident as unavailable. Another CNA, upon starting her shift, found the resident cold and stiff to the touch but did not report this to nursing staff. When the resident was eventually found unresponsive, staff initiated CPR and called EMS, but EMS and hospital records indicated the resident had been deceased for several hours prior to discovery, exhibiting rigor mortis and a significantly lowered body temperature. Interviews with staff revealed a lack of timely and appropriate assessment, failure to follow care plan interventions, and inaccurate or delayed documentation of care and vital signs. There was also a lack of clear communication and role assignment during the emergency response. The facility's policies required accurate documentation and care based on comprehensive assessment, but these were not followed. The failure to provide timely care, recognize a change in condition, and initiate life-saving interventions resulted in Immediate Jeopardy for the resident.