Failure to Monitor Change in Condition and Initiate Timely Intervention
Penalty
Summary
A deficiency occurred when facility staff failed to adequately monitor a resident who experienced a change in level of consciousness and decreased oxygen saturation. The resident, who had been admitted for rehabilitation following a left leg fracture and had a history of muscle weakness and altered mental status, was initially alert and oriented. Over the course of her stay, documentation showed a decline in her mental status, with increasing somnolence and uncooperative behavior, as well as decreasing oxygen saturation levels, including a reading as low as 88% on room air. Despite these significant changes, staff did not consistently perform or document frequent assessments of the resident's vital signs or mental status as required by facility policy and the medical provider's instructions. Oxygen therapy was not initiated when the resident's oxygen saturation dropped below 90%, and there was no documentation of follow-up assessments or escalation of care. Additionally, neither the resident nor her representative was offered a prompt transfer to the hospital for further evaluation, even though the resident's POLST indicated a preference for full treatment, including hospital transfer if indicated. Interviews with staff revealed a lack of clarity and follow-through regarding monitoring protocols, initiation of oxygen therapy, and the process for offering hospital transfer. Staff acknowledged that vital signs were not taken as frequently as expected and that opportunities to escalate care or offer transfer were missed. The resident ultimately experienced increased respiratory distress, required emergency intervention, and was pronounced dead after resuscitation efforts.