F0684

G

Failure to Assess and Notify Provider for Resident’s Change in Condition Leading to Hospital Transfer

Caseyville, Illinois Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess and respond to a clear change in condition for one resident with significant respiratory and chronic health issues. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, pneumonia, nasal congestion, and postnasal drip, and was normally alert, sociable, and ate 75–100% of meals in the main dining room while self-propelling in a wheelchair. Over a weekend period, nursing staff documented administration of multiple PRN medications for cough, congestion, sinus allergies, and pain, and recorded limited vital signs that often omitted temperature, respirations, and oxygen saturation. Despite these PRN administrations and the resident’s underlying COPD and respiratory history, there was no documented nursing assessment explaining why the PRNs were given, no documented lung assessment, and no comprehensive evaluation of the resident’s status.

During this same timeframe, multiple CNAs observed and reported that the resident was not at her usual baseline. CNAs stated the resident refused to leave her room, refused meals, remained in bed, and repeatedly said she did not feel well. One CNA reported that the resident refused to eat all weekend and stayed in bed, and another CNA reported that the resident, who usually ate 75–100% of dinner in the dining room, refused to come out of her room and refused dinner on consecutive days. These concerns were reported to nursing staff, but there is no documentation that licensed nurses performed a head-to-toe assessment, obtained full sets of vital signs including oxygen saturation in response to these reports, or documented any change from baseline. The LPN primarily assigned to the resident over these days acknowledged that the resident was not her usual “jolly chipper self,” stayed in her room, was not eating well, and stated she felt “crappy,” yet the LPN did not notify the provider and could not explain why.

On the following day, additional changes were observed and reported. A CNA assigned that morning noted the resident complained of nausea, refused breakfast, remained in bed past her usual time, had vomited on her blanket and clothes, and was incontinent of bowel and bladder despite usually being continent. These findings were reported to the LPN, but the CNA did not take vital signs because she was not asked to do so, and there is no corresponding nursing assessment documented in the record. Another LPN, while walking down the hall, was alerted by a CNA that the resident did not look good and was not herself; he observed that the resident appeared drained with an ashy facial color and reported this to the assigned LPN in the presence of the nurse practitioner. The nurse practitioner then assessed the resident, documented increased fatigue, weakness, diarrhea, altered mental status, ashen/grey skin color, lethargy, foul-smelling diarrhea, poor oral intake, and that the resident was not at her baseline, and arranged transfer to the emergency room. The resident was subsequently admitted to the hospital and diagnosed with RSV. Throughout the period leading up to this transfer, the facility’s own policy required licensed staff to perform appropriate physical assessments, obtain full vital signs, and notify the physician immediately upon recognition of an acute change in condition, but the record shows no such timely assessment or provider notification during the days when the resident’s condition and behavior had clearly changed.

The DON stated that when a resident with COPD exhibits respiratory symptoms, she expects nurses to obtain full vital signs including oxygen saturation, assess lung sounds, and document these findings, and that when a normally sociable, good eater refuses to leave their room or refuses meals, this warrants a head-to-toe assessment and provider notification. The nurse practitioner similarly stated that for this resident with COPD, she expected staff to take full vital signs including oxygen saturation, assess lung sounds, document the assessment, and notify her of respiratory status so she could determine if additional treatment or transfer was needed. Both the DON and the nurse practitioner reported that they were not notified of the resident’s refusal of meals, persistent reports of not feeling well, administration of multiple PRN respiratory medications, vomiting, diarrhea, or other changes over the weekend. The facility’s written policy on notification of changes in condition required immediate physician notification and follow-up assessment with documentation of vital signs, pain, orientation, and changes from baseline for any acute change in condition, but the documentation and staff interviews show that these steps were not carried out for this resident during the period in question.