Failure to Provide Timely Assessment, Monitoring, and Intervention After Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to a resident following a significant change in condition. The resident, who had a history of cerebral vascular disease, anxiety, and hypertension, experienced an elevated temperature and dysuria. Despite the physician ordering a urinalysis and urine culture, there was no evidence that the facility ensured timely receipt, review, or action on the test results. When the laboratory reported conflicting results and requested a new specimen, the facility did not ensure timely completion of the reordered testing. Abnormal urinalysis findings and persistent fevers were documented, but the facility did not ensure timely receipt of the culture and sensitivity results needed to guide treatment. The resident continued to experience elevated temperatures, and it was not until several days later that the physician was notified again and additional diagnostic tests were ordered. Ultimately, the resident was found to have a significant infection and impaired kidney function, requiring hospitalization for acute kidney injury. Additionally, the facility failed to identify and address the resident's inadequate fluid intake during this period. The resident's estimated daily fluid requirement was documented, but daily intake records showed that the resident consistently failed to meet these needs over a two-week period. There was no evidence that the facility reassessed the resident's hydration status, implemented interventions to increase fluid consumption, or notified the physician of the ongoing inadequate intake, even as the resident was experiencing infection and persistent fever. The combination of delayed follow-up on diagnostic testing, lack of timely intervention for abnormal findings, and failure to monitor and address inadequate fluid intake contributed to the resident's decline and subsequent hospitalization. The facility did not meet regulatory requirements for timely assessment, monitoring, and intervention in response to a significant change in condition, nor did it maintain accurate and complete records as required.