Failure to Assess and Intervene for Resident With Fever and Mental Status Change
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and intervene when a resident exhibited an elevated temperature and a change in mental status. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. The care plan noted memory problems but did not include directives for staff response to a mental status change. During observation, an LPN attempted to wake the resident, who was lethargic and required repeated tactile stimulation to respond. The LPN moved the resident to a brighter area and requested a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice. The LPN then directed a CNA to return the resident to her room. Despite recognizing that the resident was semi-responsive, with a temperature of 100.4°F and refusal of Tylenol, the LPN left the unit for lunch without contacting the provider or arranging for further assessment or monitoring by another nurse. A progress note documented the resident as semi-responsive, responding only to touch and voice, with a temperature of 100.4°F and refusal of Tylenol. Interviews with other nursing staff indicated that a temperature of 100.4°F and decreased responsiveness constituted a significant change in condition that warranted provider notification, frequent reassessment, and documentation. The LPN later acknowledged that the event was a change in condition and that she did not contact the provider until after returning from lunch. An eINTERACT Change in Condition Evaluation was completed but did not include any interventions, and the progress notes lacked follow-up assessments or interventions. The facility did not have a policy directly addressing assessment and interventions for such changes in condition.
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