Failure to Monitor and Document Vital Signs After Change in Condition
Penalty
Summary
Facility nurses failed to provide treatment and care in accordance with professional standards of practice when they did not monitor and document a resident's vital signs after a documented change in condition. The resident was admitted with pneumonia, type 2 diabetes mellitus, and dysphagia, and had severe cognitive impairment and dependence on staff for most activities of daily living. On 2/28/2026 at 6:21 PM, the resident had an elevated temperature of 100.2°F, and the nurse practitioner was contacted. The SBAR form and progress note indicated that the nurse practitioner ordered monitoring of the resident's vital signs following this elevated temperature. The DON stated that nurses normally monitor residents' vital signs once a day, but when instructed to monitor vital signs after a change in condition, staff should check them every 2–4 hours. The nurse practitioner confirmed that orders included monitoring vital signs. An LVN reported checking the resident's vital signs 2–3 times during the night shift following the fever but acknowledged not documenting them because they were within normal limits. The DON stated that if vital signs were not documented, then staff did not monitor them. Review of facility policies on acute condition changes and charting/documentation showed that staff were required to monitor and document the resident's progress, responses to treatment, and any changes in condition, including objective observations and services performed.
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