F0580

D

Failure to Notify Provider of Abnormal Vital Signs and Change in Eating Status

Tolland, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely provider notification of a significant change in condition for one resident, resulting in delayed medical intervention and subsequent hospital transfer. The resident was admitted with acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer, and was care planned for nutritional problems with interventions to monitor and report signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, and refusal to eat. On admission, the resident was documented as cognitively intact, independent with supervision for feeding, and without chewing or swallowing problems, with a regular diet and thin liquids ordered. Progress notes shortly before the event documented ongoing nausea, aspiration precautions, and use of Zofran with good effect, with instructions to continue monitoring for nausea and vomiting.

On the morning of the incident date, a nursing note documented the resident as alert, able to make needs known, with stable vital signs and no distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range of 60–100 BPM, but the clinical record contained no evidence that a provider was notified of this abnormal vital sign, despite facility policy requiring provider notification and documentation when vital signs significantly deviate from baseline. A subsequent nursing note by the same LPN that afternoon described the resident as alert with some forgetfulness, stable vital signs, no respiratory or cardiac distress, no cough or congestion, denial of nausea, and fair appetite, again without documentation of provider notification regarding the earlier abnormal pulse.

Later that day, staff identified more pronounced changes in the resident’s condition. According to interviews, a nursing assistant reported to an LPN that the resident, who normally ate independently, was not eating and required assistance, and the LPN instructed the assistant to help feed the resident and reported altered mental status and poor intake to an RN. A family member reported arriving and finding the resident lying on the side with the head of bed flat, breathing heavily, dribbling liquid from the mouth while a nursing assistant continued spooning liquid into the resident’s mouth, prompting the family member to seek the nursing supervisor and state the resident was gasping for air and needed hospital care. An RN assessment documented the resident as lethargic, confused, not responding, with low BP and a pulse of 52 BPM, and an APRN note identified low BP, bradycardia, pallor, cool skin, and concern for possible sepsis in the setting of chronic wounds, leading to transfer to the ED. EMS records documented severe hypoxia on arrival, and hospital records showed bilateral pleural effusions and lower lobe consolidation/atelectasis; the resident expired the same day. Interviews with the APRN and DNS confirmed expectations that abnormal vital signs and significant changes in eating status or mentation should trigger timely provider notification and assessment, which were not documented in this case.