F0684

J

Failure to Recognize and Respond to Resident’s Multi‑Day Change in Condition

Little Chute, Wisconsin Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and appropriately respond to a resident’s change in condition over several days following admission after major spinal surgery. The resident was admitted after a C3–C4 laminectomy with diagnoses including cervical spondylosis, diabetes, hypertension, hypothyroidism, atrial fibrillation, and congestive heart failure. On admission, the resident was documented as alert and oriented x4, able to make needs known, with clear lungs on room air and a patent Foley catheter draining clear amber urine. The facility’s policy on change in condition required staff to assess the need for immediate care, provide emergency care as needed, and evaluate the resident, including vital signs, oxygen saturation, blood glucose, and alterations in level of consciousness, and to notify the physician immediately for acute or sudden onset symptoms.

Beginning the day after admission, the resident showed multiple documented changes in condition. Progress notes indicated the resident became drowsy and hard of hearing, with the diet downgraded to pureed per the resident’s choice and medications crushed due to swallowing difficulty. On one night, the resident’s oxygen saturation dropped to 79%, improving only to 84% after deep breathing, leading to an order for supplemental oxygen at 2–5 liters, and the resident was placed on 2 liters. Subsequent notes described the resident sleeping throughout a shift, being only alert and oriented x2, spending a lot of time sleeping, and having blood glucose of 45 with involuntary jolting arm movements consistent with hypoglycemia, requiring two doses of 40% glucose gel. A change in condition evaluation documented abnormal vital signs, decreased food and fluid intake, and other changes such as talking less, being tired, weak, confused, and drowsy. Additional notes recorded a slight cough, low blood pressure of 94/52 with an order to hold hydralazine, continued need for 2 liters of oxygen with oxygen saturation at 93%, poor eating, sips of orange juice through the night, and a productive cough with mucus.

Despite these ongoing changes, the facility did not initiate and follow through with an appropriate change in condition response. During a care conference, the resident’s family reported concerns about the resident’s eating, confusion, and overall medical condition to the DON. The following morning, when an RN obtained the resident’s vital signs, the blood pressure was 102/53, and the RN attempted to administer medications in pudding but was unable to arouse the resident, who did not drink or open their eyes. The RN left the room and did not return, did not perform a further assessment, did not check the resident’s blood sugar, and did not promptly notify medical staff, despite the family member’s expressed concern that the resident was not eating or drinking and appeared unresponsive. The family member later informed the RN they were going to call 911. When EMS arrived and asked about the resident’s blood sugar, facility staff reported they did not know. EMS found the resident’s blood sugar to be 42, and the resident was subsequently admitted to the hospital with diagnoses including severe hypoglycemia with coma requiring emergent IV glucose administration, sepsis secondary to acute cystitis, depressed Glasgow Coma Scale with decreased responsiveness, and acute kidney injury. The surveyors determined that the facility failed to recognize and appropriately respond to the resident’s change in condition over several days, leading to a finding of immediate jeopardy.

Removal Plan

• Reviewed current residents with like diagnoses to ensure appropriate monitoring and interventions were in place.
• Reviewed residents' progress notes and vital signs to identify residents with a potential change in condition that required provider notification, care plan changes, or additional monitoring.
• Educated licensed nurses on the need to promptly recognize, assess and report a change in condition, including the importance of implementing appropriate follow-up monitoring.
• Educated CNAs on recognizing and reporting changes in condition to a licensed nurse.
• Initiated audits to ensure monitoring protocols are in place for new admissions with diabetes.
• Initiated audits of nursing documentation to ensure changes in condition are promptly identified, pertinent and accurate medical information is communicated to the physician, and appropriate monitoring interventions are implemented.