Failure to Respond to Resident's Acute Change in Condition Due to Misinterpretation of DNR Status
Penalty
Summary
The facility failed to assess, recognize, escalate, and properly respond to a significant change in condition for a resident who experienced symptoms consistent with a stroke. The resident, who had a history of stroke and was cognitively intact, reported new onset slurred speech and right-sided weakness to staff, explicitly stating she believed she was having a stroke. Despite these acute symptoms and her direct communication, staff only contacted the Nurse Practitioner (NP), who instructed them to place the resident back in bed and monitor her, citing her DNR status as a reason for not pursuing further intervention. The NP did not assess the resident in person, and no further escalation to the Medical Doctor (MD) occurred, even though the resident was not in need of resuscitation but required a higher level of care. Staff interviews revealed that both the LVN and CNA observed clear signs of neurological decline, including facial droop, drooling, and loss of mobility, which were significant changes from the resident's baseline. The CNA noted that the resident, previously able to move independently, now required assistance from three staff members to return to bed. Documentation in the resident's records confirmed these changes, and progress notes indicated low oxygen saturation and elevated blood pressure. Despite these findings, the only action taken was to monitor the resident, and the NP did not visit or reassess the resident during the night. The MD later stated he was not contacted and would have reviewed the resident's POLST and wishes had he been notified. The resident's POLST indicated she did not want resuscitation but did want selective treatment for medical conditions, including IV antibiotics, fluids, and non-invasive airway support. Facility policy required prompt notification of the physician and family for significant changes in condition, but this did not occur. The resident was eventually transferred to the hospital after further decline, where she was diagnosed with a left thalamic intracranial hemorrhage and experienced a marked decline in functional abilities. The failure to escalate care and provide timely intervention resulted in a delay in treatment for a critical medical emergency.