Failure to Assess and Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with professional standards of practice following a change in condition. The resident, who had a history of multiple fractures, end-stage renal disease, and severe osteoporosis, experienced a significant increase in pain and reported hearing a 'pop' in the left leg during a transfer. Despite these symptoms and the resident's complaints of severe pain, there was no documented assessment or ongoing monitoring of the affected limb as required by the resident's care plan. Specifically, there was no documentation of assessments for edema, bruising, skin temperature changes, loss of sensation, or pulses distal to the suspected fracture site. Nursing staff, including a CNA and two RNs, were present during the incident and were aware of the resident's complaints of pain. However, the night shift RN did not perform an assessment after the resident expressed pain during movement. The day shift RN was notified of the pain upon the resident's return from dialysis and contacted the nurse practitioner, who ordered an x-ray. Despite the resident's continued complaints of significant pain, there was a lack of documented reassessment and monitoring throughout the shifts, and pain management was not consistently provided according to the resident's needs. The facility did not have a change in condition policy and procedure, and staff interviews confirmed that a full assessment, including vital signs and evaluation of the injury site, should have been completed and documented. The lack of timely and thorough assessment, documentation, and ongoing monitoring resulted in a delay in identifying a complete oblique fracture of the left femur with displacement, which was only confirmed after an x-ray was eventually performed and the resident was sent to the hospital for further evaluation.