Failure to Timely Respond and Document Resident Change of Condition
Penalty
Summary
The deficiency involves staff failure to respond timely and completely to a resident’s change of condition and to document required baseline assessment data. The facility’s Acute Condition Changes-Clinical Protocol, revised 3/2018, required nurses to assess and document/report baseline information including vital signs, neurological status, current pain level, level of consciousness, and onset, duration, and severity of the condition. Resident 4, who had multiple sclerosis, opioid use, and chronic pain, was cognitively intact per a Quarterly MDS with a BIMS score of 15. On 11/25/25, a Blood Pressure Summary Report showed the resident’s blood pressure was 86/53 at 5:00 AM as taken by an LPN (Staff 6). A progress note at 6:50 AM documented the blood pressure as 70/50, and that Staff 6 called the provider and 911, but no additional assessment information was recorded. Interviews and external records showed that staff recognized abnormal findings and altered responsiveness but did not promptly act or fully document the change of condition. A CNA (Staff 14) reported that during the night the resident appeared to be sleeping, and at 5:00 AM the resident’s blood pressure was very low, prompting her to alert Staff 6. Staff 14 and Staff 6 provided incontinence care and noted it was unusual that the resident did not wake up during care and did not respond, despite typically waking when laid flat. Staff 6 stated the resident was unable to be awakened and had an abnormally low blood pressure, after which she called the provider and then 911. A Fire and Rescue Public Incident Report documented that the facility reported the resident was found with altered mental status at 5:00 AM, with EMS called at 6:46 AM and arrival at 6:50 AM, when Narcan was administered and vital signs improved. A subsequent hospital discharge summary documented admission for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy, and acute hypoxic/hypercapnic respiratory failure. The Administrator (Staff 1) acknowledged there was a delay in staff response to the change of condition and that the progress notes lacked the required baseline information.
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