Failure to Timely Monitor and Assess Resident with Acute Symptoms
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including chronic kidney disease, heart failure, COPD, anemia, and schizophrenia, was not timely or adequately monitored and assessed after reporting new symptoms. The resident, who was cognitively intact, complained of generalized body aches and cold symptoms during the overnight shift and was given Tylenol per orders. Despite these complaints and the resident being observed in the bathroom at unusual times, there was no documented evidence that the nurse checked the resident's vital signs or performed further assessment during the shift. On the following day, the resident was found with a bucket and reported nausea and vomiting that began early in the morning. The nurse aide promptly informed the charge nurse, noting that this was not typical for the resident and requested immediate attention. The resident continued to vomit throughout the morning and after lunch, and was later observed undressed, rocking back and forth, and expressing feeling neither hot nor cold. Despite these ongoing symptoms, only one set of vital signs was documented for the entire day, and the resident's status was not effectively communicated during the change of shift report. The lack of timely and thorough assessment, including failure to monitor vital signs after the onset of new symptoms and inadequate communication between staff, contributed to the deficiency. The resident was ultimately found unresponsive in the evening, and resuscitation efforts were unsuccessful. The survey identified that the facility failed to ensure prompt and adequate monitoring and assessment of the resident's changing medical condition.