Failure to Assess and Timely Complete UA for Resident With Ongoing Weakness and Mental Status Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the resident’s goals and preferences when a resident experienced a change in condition. The resident was admitted with multiple diagnoses including chronic respiratory failure, diabetes, dementia, depression, and muscle weakness. On 12/26, a doctor/nursing communication note documented ongoing dizziness and upper body weakness, with a provider indicating a follow-up would be scheduled. On 12/30, a physician’s history and physical note indicated a pending urinalysis related to dysuria and altered mental status. On 1/4, nursing documented increased weakness and difficulty with transfers and notified physical therapy for an evaluation. On 1/6, nursing documented the resident had a “tick,” dropping arms and head, and staff were directed to collect a urine specimen after the resident was found soiled, although she was usually continent. On 1/7, nursing documented that a UA and culture were collected and sent to a local laboratory, and later that day the lab faxed positive UA results indicating infection. The resident’s record did not include documentation of nursing assessment, vital signs, or UA collection related to her change in mental status and weakness between 12/30 and 1/6, despite these ongoing symptoms. Vital signs were only documented on 1/6 and 1/8. On 1/8, the resident’s POA called the facility expressing concern that the resident “isn’t right” and requested transfer to the ER, and the resident was transferred via non-emergent services. Hospital records from that day documented the resident was seen for weakness and dizziness lasting 1–2 weeks and was admitted with findings including weakness, expressive aphasia, stroke-like symptoms, acute kidney injury on chronic kidney insufficiency, hyperkalemia, and UTI. The DON stated that staff usually complete medical orders within 24 hours if a STAT order is not placed and did not provide a response when asked why the UA had not been completed around 12/30, and also stated that vitals are typically taken only every 30–60 days unless ordered otherwise.
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