F0684

G

Failure to Assess and Monitor Resident After Severe Pain and Change in Condition

Evansville, Wisconsin Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and the facility’s own change of condition policy. The Wisconsin Nurse Practice Act (N6.03) requires RNs to use the full nursing process—assessment, planning, intervention, and evaluation—while the facility’s Change of Condition policy requires prompt notification of the practitioner for uncontrolled pain or need for hospital transfer, and completion of an assessment with documentation of findings, including vital signs and pain. On one date, the resident reported increased abdominal and low back pain, was crying, and rated the pain as 10/10. The nurse contacted the NP, who ordered the resident sent to the hospital, but the resident refused transfer. Despite this significant change in condition and uncontrolled pain, there is no documentation that an RN assessment was completed or that nursing staff continued to monitor the resident’s condition.

The resident had multiple chronic conditions, including bipolar disorder, other chronic pain, low back pain, fibromyalgia, schizoaffective disorder, generalized anxiety disorder, psychophysiologic insomnia, and adjustment disorder. The resident’s MDS showed a BIMS score of 15/15, indicating intact cognition. The comprehensive care plan identified altered respiratory status/difficulty breathing related to chronic respiratory failure, restrictive lung disease, and obstructive sleep apnea, with interventions including CPAP per MD orders, elevating the head of bed, and monitoring for and documenting changes in orientation, restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress such as increased respirations, decreased pulse oximetry, tachycardia, restlessness, diaphoresis, headache, lethargy, confusion, hemoptysis, cough, pleuritic pain, and accessory muscle use. Despite these care plan directives, there is no evidence in the medical record that the resident was assessed or monitored after reporting severe pain on the first day.

On the following day, a CNA summoned the nurse to the resident’s room at approximately 7:00 AM. The resident was unable to sit at the edge of the bed unassisted, had rapid respirations, increased pain, and altered mental status. The nurse confirmed with the resident that she now agreed to transfer to the ER, and 911 was called; the resident left via ambulance around 7:30 AM. The resident was admitted to the hospital ICU with diagnoses including pneumonia, acute on chronic respiratory failure, sepsis with acute hypoxic respiratory failure, and septic shock. Hospital documentation noted that the resident reported worsening dyspnea over the prior 24 hours, was in mild to moderate respiratory distress with increased work of breathing, low-grade fever, mild tachycardia, and later became hypotensive, requiring sepsis fluid bolus, IV fluids, IV pressors, and non-invasive ventilation. There is no evidence in the facility record that a nurse completed an assessment on the morning of transfer, beyond the resident’s report that only a temperature was taken and no other vital signs were obtained.

In interviews, the resident stated she had been telling staff for about a week, multiple times per day, that she did not feel well and thought she had a urinary infection, and that staff did not listen. She reported that there was no assessment or monitoring on the day she first reported severe pain, and that on the following day she was "out of it" and unable to sit up, and that before transfer the nurse only took her temperature. The RN who worked on the first day stated she recalled the resident refusing to go to the ER and thought she might have done an abdominal assessment but could not remember and could not recall what she had documented. The DON confirmed that there was no documentation of further assessment or monitoring on either day and stated she would have expected the nurse to take vital signs, complete an assessment at least every shift, and enter a progress note. The lack of documented RN assessment, ongoing monitoring, and vital signs in response to the resident’s uncontrolled 10/10 pain and subsequent deterioration constitutes the cited failure to provide care in accordance with professional standards and facility policy.