Failure to Address Changes in Condition and Ensure Timely Intervention
Penalty
Summary
The facility failed to properly address changes in condition for two residents, resulting in deficiencies related to timely assessment, intervention, and communication with medical providers. One resident with a history of bipolar disorder, morbid obesity, stroke, and other conditions reported chest pain and was observed grabbing at her chest. Despite being a full code, she refused hospital transport multiple times, was given an antacid without a physician's order, and the physician was notified only after administration. Later that evening, she was found on the floor, assessed for injury, and again refused hospital evaluation. She was subsequently found unresponsive in her wheelchair and CPR was initiated, but she could not be revived. Documentation revealed that she had refused assessments and vital signs throughout the day, and there was a lack of documented follow-up care or assessment after her initial complaint of chest pain. Another resident, who was moderately cognitively impaired and receiving hospice services, experienced a change in condition characterized by unresponsiveness, altered mental status, and abnormal breathing. Although the nurse practitioner was eventually notified and ordered hospital transfer, prior to this event, staff failed to assess or notify hospice or the physician about the resident's declining condition. Interviews revealed that staff were unaware of the resident's code status and did not know where to locate it, leading to a lack of timely intervention. The resident was ultimately found unresponsive and sent to the hospital, where he was intubated and later passed away. Facility policy required staff to recognize and communicate significant changes in residents' health status, make detailed observations, and report pertinent information to the physician. However, in both cases, staff did not follow these protocols, resulting in missed assessments, delayed notifications, and inadequate documentation of the residents' conditions and care provided during acute changes.