Failure to Recognize and Report Change in Condition and Complete Ordered Labs
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including type 2 diabetes, dementia, and hypertensive chronic kidney disease. Staff did not recognize or report a significant change in the resident's condition, specifically a marked decrease in the frequency of daily brief changes, which was a notable deviation from her baseline of 15-20 changes per day. Multiple CNAs and a licensed nurse confirmed that the reduced number of brief changes was abnormal for this resident, yet this change was not documented or communicated to the Medical Director or Director of Nursing as required by facility policy. Additionally, the facility failed to ensure that a laboratory blood test ordered by the Medical Director was completed. After the resident initially refused the lab draw, staff did not follow up by placing a new lab slip in the requisition binder or entering a new electronic order, resulting in the lab not being drawn as instructed. The Medical Director was not notified that the labs were not completed, and there was no follow-up to ensure the order was fulfilled. Interviews revealed confusion among staff regarding responsibility for ensuring lab orders were carried out, and the DON acknowledged that it was his responsibility to follow up on lab work but did not do so in this case. The resident subsequently exhibited further signs of deterioration, including persistently elevated blood glucose levels, calling out for help, and a thready pulse with low oxygen saturation. Despite these changes, there was inadequate assessment and communication with the Medical Director. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock, acute respiratory failure, profound hyperkalemia, acute kidney injury, and other critical conditions. She was placed on hospice care upon return to the facility and passed away shortly thereafter.