Failure to Assess and Monitor Change in Condition Following Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide care and treatment in accordance with professional standards of practice, specifically related to the assessment and monitoring of a resident's change in condition. The resident, who had multiple complex medical diagnoses including diabetes with neurological complications, chronic kidney disease, fibromyalgia, epilepsy, osteoporosis, and Parkinson's disease, experienced an increase in pain and swelling in her leg/foot after returning from a dental appointment. Despite the resident's report of pain and visible symptoms such as swelling and bruising, the facility did not complete a timely RN assessment, nor did staff continuously assess, record, or monitor the resident's change in condition for new or worsening symptoms as required by facility policy and the Wisconsin Nurse Practice Act. Documentation revealed inconsistencies and omissions in the resident's medical record. Pain assessments recorded by facility staff often indicated no pain, even when hospice notes documented severe pain (up to 9 out of 10). The facility administered as-needed pain medication despite documenting pain scores of zero. There was no evidence of ongoing monitoring of the resident's edema, range of motion, or bruising following the initial report of injury. Additionally, the facility failed to document an incident report for the injury, did not provide hospice nurse progress notes as part of the medical record, and did not communicate critical changes in the resident's condition to the appropriate providers in a timely manner. Interviews with facility staff, hospice staff, and the resident's representative highlighted further lapses. Staff were unclear about the circumstances of the injury, and there was no documentation of a safety or positioning assessment prior to transporting the resident to the dental appointment. The resident's decline, subsequent x-ray findings of a questionable non-displaced tibial fracture, and eventual death were not adequately assessed or monitored by facility nursing staff. The lack of systematic and continual assessment, documentation, and communication regarding the resident's change in condition directly contributed to the deficiency cited by surveyors.