F0580

G

Failure to Recognize and Report Acute Change in Condition and Swallowing Difficulty

Clovis, California Survey Completed on 01-05-2026

Penalty

Fine: $15,935

Summary

The deficiency involves the facility’s failure to ensure timely and complete physician notification and accurate assessment/documentation of a resident’s acute physical and mental status changes. An 81‑year‑old resident admitted for rehab after a motor vehicle accident had multiple diagnoses including diabetes mellitus II, hypertension, atrial fibrillation, hypothyroidism, neuromuscular bladder dysfunction, and multiple fractures. On admission and in subsequent assessments, she was documented as alert and oriented, with a Glasgow Coma Scale of 15 and a BIMS score of 13, indicating she was cognitively intact, able to speak in full sentences, make her needs known, and eat independently with tray setup. Therapy and nursing notes prior to the incident described her as motivated, vocal, and actively participating in PT/OT, with meal intake generally ranging from 26–100%.

On the morning in question, the resident’s daughter arrived shortly after 10 a.m. and observed that the resident was not her usual self, reporting an excruciating headache, refusing therapy, and refusing to eat. The daughter stated the resident, normally eager to converse and participate in therapy, did not want to talk and later fell asleep around lunchtime. Documentation later showed the resident refused breakfast, lunch, and dinner that day, a change from her prior intake, but these refusals were not communicated to the RN by CNA staff and were not reported to the physician by the RN. When RN 1 entered the room before 2 p.m. to administer scheduled sodium chloride, the daughter voiced concerns about the resident’s condition. RN 1 attempted to wake the resident, noted that she could nod yes/no and squeeze hands on command, and proceeded to administer oral medication and soda via straw despite the resident’s difficulty drinking and swallowing.

RN 1 documented that the resident sucked on the medication and did not swallow it, prompting RN 1 to place a gloved hand into the resident’s mouth to feel for the pill until she believed it was swallowed. This action was later described by the DON and ADON as not standard practice and not taught in the facility. RN 1 did not document or report to the physician that the resident had difficulty swallowing, that a mouth sweep was performed, or that meals had been refused. The SBAR completed by RN 1 that afternoon lacked a full assessment and omitted key findings such as altered mental status, swallowing difficulty, and meal refusals. The ADON, who was called to the room due to the daughter’s concern, only visually observed while RN 1 assessed the resident and did not perform an independent physical assessment. The DON, MD, and RN 1 all later acknowledged that the physician was not provided with a complete and accurate clinical picture of the resident’s change in condition, including the acute neurological and swallowing changes that represented a significant deviation from her baseline. The resident’s condition continued to decline throughout the day until the evening nurse (RN 2) performed a more detailed assessment, documented lethargy, difficulty arousing, decreased responsiveness, and abnormal oxygen saturation, and then notified the provider, who ordered transfer to the hospital, where the resident was diagnosed with a large intracranial hemorrhage and coma.

The facility’s own policies required nurses to notify the physician for significant changes in physical, emotional, or mental condition, including refusal of treatment, and to gather and communicate detailed, pertinent information prior to notification. Policies and job descriptions also required licensed nurses and CNAs to identify, document, and report changes in condition, and for RNs to ensure nurses’ notes were informative and accurately reflected the resident’s response to care. Interviews with the LVN, CNA, MD, DON, and RN 2 confirmed that changes such as altered mental status, lethargy, refusal of meals, difficulty swallowing medications, and deviations from baseline communication and activity should be promptly assessed, documented, and reported using tools like SBAR. In this case, the facility failed to ensure that staff recognized and escalated the resident’s acute neurological and swallowing changes, failed to ensure accurate and complete documentation of those changes, and failed to ensure that the physician received a full and accurate description of the resident’s condition in a timely manner.

Professional references cited in the report emphasized that altered mental status requires early recognition, thorough history and physical examination (including neurologic assessment), and close communication among healthcare providers, and that clear, complete nurse‑physician communication is essential for safe patient management. The DON also referenced a standard of practice document indicating that when a patient is unable to swallow medication and the nurse must retrieve or assess for medication in the mouth, the dose should be removed and withheld and the provider notified immediately. The DON stated this did not occur with RN 1, and that RN 1 failed to conduct and document a full neurological assessment and failed to provide the primary physician with a complete and accurate assessment of the resident’s acute change in condition on the day in question.