Failure to Reassess After Change in Condition and Notify MD of Lab Refusal
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for one resident following documented changes in condition. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and hypertension, returned to the facility on 4/13/2025 at 4:30 p.m. with a reported change in condition involving left eye drooping and unequal pupils. A Change of Condition (COC) form documented that an LVN assessed the resident and noted no drooping, the left eye closed but able to open without difficulty, and redness of the left eye. However, review of the nursing progress notes for the following day shift on 4/14/2025 showed no documentation of a required reassessment after this change in condition, despite facility practice that residents are to be monitored for 72 hours with reassessments each shift following a COC. A second deficiency occurred when the facility failed to notify the resident’s physician that ordered laboratory tests were not fully completed due to the resident’s refusal to provide a urine specimen. On 9/18/2025, a COC form documented that the resident exhibited increased sleepiness and an altered routine, prompting notification of the physician, who ordered stat labs including a CBC, CMP, Keppra level, UA, and urine C&S. The laboratory requisition form for that date indicated the resident refused to provide a urine sample, and therefore the UA and C&S were not submitted for analysis. Nursing progress notes documented that the physician was informed of the CBC, CMP, and Keppra results, but there was no documentation that the physician was notified of the resident’s refusal to provide the urine specimen or that the UA and C&S were not completed. Interviews with facility staff confirmed these lapses. An LVN stated that after a COC, residents are to be monitored for three days with reassessments each shift, and acknowledged there was no documented reassessment on the day shift following the 4/13/2025 COC. The DON similarly stated that the standard of practice is to complete and document reassessments on each nursing shift after a COC and to notify the physician of any changes in condition, and confirmed there was no documented reassessment on 4/14/2025. The DON also stated that when a physician orders laboratory tests, the physician should be notified of the results, including any resident refusal to provide a specimen, and acknowledged there was no documentation that the physician was informed of the resident’s refusal to provide a urine sample on 9/18/2025. The facility’s policy on requesting, refusing, and/or discontinuing care or treatment indicated that the healthcare practitioner must be notified of treatment refusals in a timeframe determined by the resident’s condition and potential serious consequences of the request.
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