Failure to Promptly Assess and Document Change in Resident Condition
Penalty
Summary
Staff failed to provide care according to standards of practice when they did not promptly assess a resident after a noticeable change in condition. The resident, who had chronic kidney disease stage 5, encephalopathy, and a mood disorder, was observed by multiple staff members to be acting differently from her baseline. On the morning in question, the resident was incoherent, mumbling, dropping her toothbrush repeatedly, unable to lean forward to spit, and was hallucinating. These changes were reported by a CNA and a Certified Medication Tech to the LPN on duty, who was informed that the resident was not acting like herself and was talking to someone not present. Despite these reports, the LPN did not perform a face-to-face assessment of the resident. The LPN had a CNA check the resident's vital signs, which were within normal limits for the resident, but did not further evaluate the resident or document the change in condition. The LPN instructed staff to proceed with transporting the resident to her scheduled dialysis appointment, stating that dialysis staff would address the issue if it was serious. Upon arrival at the dialysis clinic, the resident's condition had further deteriorated, with slurred speech, and she was immediately sent to the hospital, where she was diagnosed with metabolic encephalopathy and hypoglycemia. Facility policy required that any change in a resident's condition be promptly assessed, documented, and reported to the physician and resident representative. The policy also required completion of an event report and documentation in the resident's chart. In this case, there was no documentation of the change in condition or the transfer to the hospital in the resident's records. Interviews with staff, including the LPN, DON, ADON, and the resident's physician and nurse practitioner, confirmed that an assessment should have been performed and documented when the change in condition was reported.