F0684

J

Failure to Act on Change in Condition and Delay in Activating 911 for Unresponsive Resident

Bridgman, Michigan Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system.

During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer.

The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer.

Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.

Removal Plan

• All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
• Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
• Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
• The monthly on call schedule was posted at the nurse's station.
• The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
• Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
• No licensed staff will be allowed to start a shift or give care until education is completed.
• Medical director was notified.
• Facility health care providers will enter their own orders into the electronic medical record.
• A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
• All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
• A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
• All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
• Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
• The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
• Emergency condition decision-support tools were implemented at the nurse's station.
• Leadership oversight was implemented to review all emergency transfers.