F0684

D

Failure to Notify Provider and Fully Assess Resident With Acute Change in Condition

Niles, Michigan Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

Licensed staff failed to follow professional standards of practice and the facility’s Acute Change in Condition policy when a resident experienced an acute change in condition. The resident, a female with dementia, mild cognitive impairment, dysphagia, cognitive communication deficit, muscle weakness, lack of coordination, and need for assistance with personal care, was documented in a nurse’s note at 2:15 AM as being confused and restless, with an oxygen saturation of 88% that improved to 93% after application of 2L O2, and with blood noted in her stool. Despite these findings, there was no documentation in the medical record of a full set of vital signs (blood pressure, temperature, pulse) for that event, and the nurse only placed a note in the physician book rather than directly contacting the provider.

Review of the physician binder showed an entry stating the resident was confused and had blood in her stool and “need to be checked,” but facility-provided provider notes contained no evidence that a provider ever evaluated the resident for the low oxygen saturation, confusion, and blood in the stool. Interviews with LPNs and the Unit Manager indicated that facility practice and standing orders required obtaining a full set of vitals, initiating oxygen per protocol, and directly contacting the provider for new issues or acute changes in condition such as altered mental status, low O2 saturation, and possible GI bleed. The DON confirmed that the nurse should have called the physician immediately rather than relying on the physician log, especially given the holiday week and upcoming weekend, and that the failure to call represented a deviation from the facility’s Acute Change in Condition policy, which requires urgent phone calls for significant changes such as abrupt confusion and frank blood in stool.