F0684

G

Failure to Recognize Change in Condition, Implement Hospice Orders, and Monitor Resident Prior to Death

Zeeland, Michigan Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly identify and act upon a resident’s change in condition, including not implementing ordered treatments and not adequately assessing or monitoring the resident prior to death. The resident was an older male with a history of stroke and on palliative care, with a guardian and advance directives specifying full code status and a desire for all available medical treatments, including transfer to the hospital when necessary. His care plans identified communication barriers (Cambodian language, dementia), risk for impaired communication, and the need to use simple, direct communication and translation support as needed. His urinary care plan directed staff to observe and report signs and symptoms of UTI, and his pain care plan documented a pain threshold of zero, with instructions to administer medications per orders and notify the practitioner if pain was present.

Hospice documentation on one evening showed a clear change in condition: strong‑smelling, dark urine for several days, abnormal UA strip with protein, elevated pH, and small amount of blood, low‑grade fever (99.4°F), tachycardia (pulse 102), abdominal tenderness with guarding over the bladder, increased agitation and behaviors, and decreased oral intake with spitting out food. Hospice contacted the physician, who prescribed Levaquin 500 mg daily for seven days for UTI symptoms, and also ordered PRN ondansetron for nausea. The hospice note indicated facility staff had reported the abnormal urine and behaviors had been present for a few days, but review of the EMR showed no documentation that the practitioner or guardian had been notified of these changes before the hospice assessment, and no symptom tracking or UTI monitoring by licensed nurses was provided. The DON acknowledged the EMR did not prompt UTI/symptom charting and that nurses were expected to perform assessments per professional standards.

After hospice obtained orders for Levaquin and ondansetron, the facility failed to transcribe these medications into the EMR or administer them at any time before the resident’s death, and there was no documentation explaining the delay or notifying a provider that treatment had not been initiated. The NHA later stated the orders were not found on the fax until two days after they were written. A nurse’s note early the next morning documented that hospice had been in the night before and that the resident had a temperature of 99.4 and pain with palpation, but there was no evidence that the nurse performed an independent physical assessment or obtained updated vital signs at that time. Despite the resident’s documented pain and an order for PRN acetaminophen 650 mg, there was no record that any pain medication was administered following the hospice assessment. Later that day, the resident received PRN Ativan for anxiety, which was documented as effective, but there was no description of the behaviors prompting its use, no linkage to possible pain, and no follow‑up pain assessment.

That evening, a nurse note recorded that the resident refused assessments and a temperature of 98.3°F was obtained, but no further assessment findings were documented, and there was no evidence of re‑approach as directed in the behavior care plan or use of observational assessment for non‑verbal pain or decline. There was also no documentation that the guardian was notified of the resident’s change in condition, refusal of assessment, or involved to assist with translation and decision‑making, despite the facility’s Notification of Changes policy and the resident’s inability to make his own decisions. CNA documentation showed no recorded care from 6:00 PM through 6:00 AM, and the NHA stated best practice was rounding every two hours. A CNA on the night shift reported being told at shift change that the resident was declining, with more pain behaviors and refusal to eat, and stated she last checked him around 1:00 AM by quickly checking his brief without disturbing him because of his behavioral history.

In the early morning hours, CNAs found the resident unresponsive and cold at approximately 4:20 AM. The RN’s note described no pulse, cold skin, fixed and dilated eyes, mottling, and large amounts of dark, rust‑colored fluid draining from the resident’s mouth and onto the bed and wall when repositioned. The RN documented “blood pooling” and lividity on the resident’s back, and both the RN and CNAs described his back as dark red to deep dark purple. The DON and NHA later reported that CPR was not initiated because RN A determined there were signs of irreversible death, although the State Operations Manual lists specific criteria for obvious clinical signs of irreversible death that differ from those described. Review of the EMR showed no documented licensed nurse assessment or CNA observation for approximately 6 hours and 45 minutes before the resident was found unresponsive. The facility’s Notification of Changes policy required prompt notification of the physician and representative for significant changes in condition and new treatments, but the record lacked evidence that these notifications occurred when the resident’s condition deteriorated and when new orders were obtained.