Failure to Recognize and Respond to Acute Change in Condition for a Full-Code Hospice Resident
Penalty
Summary
Failure to recognize, assess, and respond to an acute change in condition occurred for one cognitively intact resident who was a full code and on hospice services. The resident had diagnoses including dementia, psychotic disturbance, anxiety, and insomnia, and an MDS BIMS score of 13 indicating intact cognition. Documentation showed that the resident’s code status remained full code per the admission record, hospice plan of care, and care conferences. A progress note documented that hospice was called when the resident was nonresponsive, with vital signs recorded at that time, and hospice indicated that if the resident needed to be sent to the hospital due to coding, the facility could do so. Over the following days, multiple progress notes described the resident as very lethargic, difficult to arouse, and later not responsive, with poor or no oral intake and very little fluid intake due to inability to swallow. Staff documented shallow respirations, mouth breathing, and that the resident appeared to be actively dying, with an inability to obtain a blood pressure and a respiratory rate of 40. Notes also showed attempts to contact the resident’s son regarding code status and declining condition, with hospice being notified and acknowledging the full code status and the need to send the resident out if required. Despite these documented changes, there was no evidence in the EMR of acute assessments or systematic acute monitoring in response to the resident’s declining condition. Vital sign records showed that vital signs were obtained only five times over a 14‑day period, and no additional vital signs or acute assessments were documented during the period of decline. The resident remained unresponsive with continued decline until transfer to the hospital, where she was found in respiratory failure, intubated, and diagnosed with right lower lobe pneumonia, COVID‑19 infection, severe acidosis, hyperkalemia, and septic shock. In interview, the DON acknowledged being unable to locate documentation of an acute assessment or acute monitoring for the change in condition and stated that the resident was unresponsive with continued decline until transfer, and that there should have been acute documentation and a transfer sooner. Facility policy required prompt notification of the resident, physician, and representative of changes in condition and transfer to the hospital when necessary, but the documentation did not show that this was carried out in a timely, acute response to the resident’s change in condition.
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