Failure to Use Stop and Watch Tool for Resident Change in Condition
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to complete required Stop and Watch Early Warning Tool forms when a resident experienced observable changes in condition on two consecutive days. The resident had a history of COPD, acute respiratory distress, and dysphagia, and was severely cognitively impaired per the MDS dated 2/2/2026, requiring substantial to total assistance with most ADLs. On one morning shift, a CNA observed that the resident was congested, had a lot of phlegm, and was having difficulty swallowing food. On another shift that same day, a different CNA noted the resident was hot to the touch and had diarrhea. The resident’s responsible party also reported the resident felt hot to the touch that day. On the following day, another CNA observed the resident coughing and congested during the day shift. Facility policy and staff interviews established that when CNAs notice a change of condition, they are to complete a Stop and Watch form describing what they observe and provide copies to the licensed nurse and the Director of Staff Development, with the nurse acknowledging the form. The DON confirmed that symptoms such as congestion, significant phlegm, difficulty swallowing, and diarrhea constitute an acute condition change under the facility’s Acute Condition Changes policy, and that CNAs are expected to use the Stop and Watch tool to communicate such changes. Review of the Stop and Watch binder with the DSD revealed there were no Stop and Watch forms completed for this resident, despite the observed changes in condition and the expectation that such forms should be present even if the resident was discharged.
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