Failure to Promptly Assess and Intervene for Resident's Change in Condition
Penalty
Summary
The facility failed to promptly assess, monitor, identify, and intervene for a resident who experienced a significant change in condition, transitioning from being responsive and communicative to unresponsive. The resident had multiple complex diagnoses, including heart failure, paroxysmal atrial fibrillation, hyperlipidemia, hemiplegia, shortness of breath, acute embolism and thrombosis of deep veins, type 2 diabetes, schizophrenia, and epilepsy. Despite these risk factors, staff did not take immediate and appropriate action when the resident became unresponsive and exhibited labored breathing. Multiple staff members observed and reported the resident's deteriorating condition throughout the day. A CNA was instructed by an LPN to sit with the resident and repeatedly call their name to keep them awake, despite the resident's labored breathing and unresponsiveness. The LPN noticed the resident was sweating and reported a change in condition to the wound care coordinator, who advised monitoring the resident but did not assess the resident in person or notify the physician. Another nurse observed the resident as lethargic and unresponsive, communicated this to the wound care coordinator, and was told to obtain vital signs and inform the physician, but there was no evidence that the physician was notified at that time. Documentation shows that the resident's physician was not notified of the change in condition until much later, and there was no record of timely assessment or intervention prior to the resident's transfer to the hospital. When paramedics arrived, the resident was in cardiac arrest and subsequently expired. The facility's own policies required prompt assessment and physician notification for acute changes in condition, but these protocols were not followed, resulting in a delay in care for the resident.