F0684

D

Failure to Respond to Change in Condition and Remain With Resident During Medical Emergency

Tolland, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and appropriately respond to an acute change in condition for a resident with significant medical issues, including acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer. On admission, the resident was cognitively intact, independent with eating (with supervision), and had no documented chewing or swallowing problems. The care plan and nutrition assessment called for monitoring and reporting signs of dysphagia and aspiration risk, and the resident was on a regular diet with thin liquids. An APRN note identified ongoing nausea and that the resident was on aspiration precautions, and another APRN note documented recent nausea treated with Zofran and the need to continue monitoring for nausea and vomiting.

On the morning of the incident date, nursing documentation indicated the resident was alert, able to make needs known, and without distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range, but there was no documentation that the provider was notified, contrary to facility policy requiring notification and documentation when vital signs significantly deviate from baseline. In the early afternoon, another nursing note described the resident as alert with some forgetfulness, stable vital signs, and no respiratory or cardiac distress. By late afternoon, an RN documented via SBAR that the resident was lethargic, confused, not responding, and had low blood pressure, with vital signs showing hypotension and bradycardia. The APRN note from that time described low blood pressure, a heart rate of 52 BPM, pale cool skin, and concern for possible sepsis in the context of chronic wounds, leading to the decision to send the resident to the ED.

Around this same time, a visitor reported entering the resident’s room and finding the resident lying on their side with the head of the bed flat while a nursing assistant spoon-fed liquid into the resident’s mouth, despite the resident having eaten independently the day before. The visitor observed heavy breathing and liquid dribbling from the resident’s mouth while the nursing assistant continued to insert more liquid, prompting the visitor to tell the assistant to stop and to seek the nursing supervisor, reporting that the resident was gasping for air and needed hospital care. An LPN later stated that this was the first time she had cared for the resident and that, after being told the resident was not eating, she evaluated the resident, learned the resident normally ate independently, and directed the nursing assistant to assist with feeding. She reported that she informed an RN that the resident was not eating, required assistance, and had altered mental status, and that after low blood pressure was identified, the RN notified the APRN and the APRN ordered transfer to the ED.

EMS records and interviews revealed that EMS was dispatched and arrived within minutes, but the EMT found the resident’s room door closed and the resident alone, with no nurse or provider in or near the room and no staff meeting EMS on entry to the building. The EMT observed the resident lying on their side, drooling, with liquid on clothing, labored breathing, slightly purple lips, and severe hypoxia with an oxygen saturation of 55% on room air; oxygen was initiated at 4 L via nasal cannula. The EMT did not leave the resident to locate staff because it was unsafe to leave the resident unattended. The EMT’s partner arrived about 16 minutes later and then located the resident’s nurse, who reported that a nursing assistant had spoon-fed liquid food at about 5:00 p.m., that the resident was later found hypotensive with severely altered mental status, and that no interventions were provided before EMS arrival. Facility staff interviews confirmed that after the RN assessed the resident and called 911, she left the room to complete transfer paperwork and acknowledged that someone should have remained with the resident until EMS arrived. The DNS and APRN both stated that abnormal vital signs and significant changes in eating or mentation should be reported and that a staff member should remain with a resident during a medical emergency until EMS assumes care.

Facility policies on change of condition, vital signs, and aspiration precautions required provider notification and documentation when vital signs significantly deviated from baseline, RN assessment and documentation of changes in condition, and specific positioning and speech therapy involvement for residents on aspiration precautions. The record showed no provider notification of the abnormal pulse earlier in the day, no documented interventions prior to EMS arrival despite the resident’s acute deterioration, and that the resident was left alone in the room during a medical emergency until EMS arrived and assumed care.