F0684

J

Failure to Monitor and Treat Resident’s Acute GI and Mental Status Changes, Including Missed STAT Labs and Assessments

Crawfordsville, Indiana Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor, assess, and treat a cognitively intact resident with new onset altered mental status and gastrointestinal symptoms in a timely and thorough manner, in accordance with physician orders, care paths, and facility policies. The resident had significant medical diagnoses including prostate cancer, lung cancer, insulin‑dependent diabetes, GERD, and COPD, and a care plan identifying risk for rehospitalization with interventions such as completing labs as ordered and timely communication with the physician regarding changes in condition. Despite this, when the resident developed new symptoms of coughing, coffee‑ground emesis, feeling "drunk," and staggering while ambulating, nursing staff documented the initial episode and a physician order for a CBC and medication changes, but the CBC was never obtained and there was no further documentation of the resident’s condition that day.

On subsequent days, the resident continued to experience nausea, vomiting, confusion, dizziness, and abdominal pain, with a documented pulse of 128. The physician ordered STAT chest and abdominal x‑rays and a STAT CBC for cough, nausea, vomiting, abdominal pain, altered mental status, weakness, and dizziness. The x‑rays later showed a mild to moderate colonic stool burden contributing to a colonic ileus and a small right pleural effusion, and the physician ordered stool softeners, MiraLAX, and doxycycline. However, the STAT CBC was again not obtained prior to the resident’s death, and the laboratory request log showed the CBC was entered without being marked as STAT. The clinical record lacked documentation that the laboratory was called when the STAT lab was not completed, and there was no evidence that the facility followed its GI Symptoms and Acute Mental Status Change care paths, which called for vital signs and assessments every 4–8 hours, abdominal exams, neuro checks, and monitoring of intake/output.

Throughout this period, the record lacked documentation of ongoing assessments, follow‑up vital signs, neurological checks, abdominal assessments, or nursing interventions on multiple days when the resident was symptomatic. Although there were active PRN orders for Zofran 8 mg and Meclizine 12.5 mg for nausea, vomiting, and dizziness, there was no documentation that these were administered on the days in question; only a later order for Zofran 4 mg was documented as given once in the evening, with no subsequent nursing assessment recorded after that administration. The resident’s emergency contact was not notified by nursing staff of the change in condition, and there was no documentation that the resident or his representative was consulted regarding transfer to the hospital, despite the POST form allowing hospital transfer for stabilization and comfort. Confidential interviews indicated staff believed upper management could block hospital transfers and that the DON was aware of the resident’s deteriorating symptoms but instructed staff to wait for physician orders before sending him out. The physician reported he was not informed that vomiting and symptoms persisted for multiple days and had not ordered a hospital transfer based on the limited information provided. The resident was later found with bile‑like emesis, became unresponsive, and died in the facility, with no nursing documentation between the last evening medication administration and the time of the code.

Additional record review and interviews confirmed that there were no faxed or scanned urgent communications to the physician beyond what was already in the electronic record, and the physician’s office had no additional documentation from the facility for the days surrounding the change in condition. The facility’s own policies on nursing documentation and changes in resident condition required documentation of condition changes, vital signs, system reviews, and timely notification of the physician and resident representative when there was a significant change in physical or mental status, as well as use of INTERACT tools such as Stop and Watch and SBAR. The resident’s record lacked evidence that these tools were used or that the required notifications and assessments were consistently performed. Surveyors also noted that the facility’s laboratory services policy did not define expectations for STAT lab timelines, and the DON later acknowledged that audits had identified other missed changes in condition in additional residents during the same period.

Removal Plan

• Implemented a systemic plan that included assessments, audits, and updated care plans.
• In-serviced staff on resident assessment, change in condition, physician and resident representative notification, and laboratory policy and procedures.