F0726

K

Failure to Ensure RN Competency in Identifying Change in Condition and Appropriate Transport

Warwick, Rhode Island Survey Completed on 02-18-2026

Penalty

Fine: $115,500

Summary

The deficiency involves the facility’s failure to ensure that nursing staff had the competencies and skills to identify and respond to a resident’s change in condition, as required by facility policy and the facility assessment. The facility’s Nursing Services policy required sufficient nursing staff with appropriate competencies to assure patient safety and to identify changes in condition, including use of tools and documentation systems such as Point of Care/PointClickCare to trigger alerts. The facility assessment stated that all staff were educated, trained, and competency-checked on hire and annually, including on practices and tools used to identify resident changes in condition. However, record review showed no evidence that competencies related to identifying a change in condition had been completed for four RNs (Staff B, C, D, and Unit Manager F).

The resident involved had been admitted with diagnoses including a urinary tract infection (UTI) and had a care plan that directed staff to screen for sepsis and report a positive screen to a physician, including when two or more criteria such as pulse greater than 100, respiratory rate greater than 20 or oxygen saturation at or below 90%, or altered mental status were present. The care plan also required staff to report to the physician any changes in vital signs and/or condition, including subtle changes. During the 11:00 PM to 7:00 AM shift, RN Staff B found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased oxygen saturation. Staff B increased the oxygen flow to 4 L, after which the oxygen saturation improved, but she did not notify a provider, stating she did not consider this a change in condition and was unaware of the resident’s baseline. She reported only that the oncoming nurse should “keep an eye” on the resident and did not document or otherwise communicate in the clinical record that the resident had been without the nasal cannula, required increased oxygen, and was trying to get out of bed unassisted.

On the following shift, RN Staff C documented a change from the resident’s baseline, including decreased alertness, inability to follow simple commands or form words, and vital signs showing blood pressure 119/94, heart rate 126, respiratory rate 20, and oxygen saturation 93% on 4 L oxygen. Staff C contacted the nurse practitioner, who ordered the resident sent to the emergency department, and Staff C, along with Unit Manager RN Staff F, RN Staff D, and the nurse practitioner, decided to send the resident via a non-medical transport company rather than emergency medical services. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and had a mental status change. Hospital records showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was diagnosed with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and later expired that day. The Medical Director stated he would expect a decrease in oxygen saturation to be identified as a change in condition with provider notification, and that emergency medical services should transport a resident experiencing a change in condition. The DON was unable to provide evidence that Staff B, C, D, and F had received education on identifying and addressing a resident’s change in condition.