Failure to Implement Care Plan After Episodes of Loss of Consciousness
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who experienced episodes of brief loss of consciousness (LOC). The resident had multiple significant diagnoses, including hypertension, multiple segmental thrombotic pulmonary emboli, cerebral infarction with aphasia, muscle weakness, and facial weakness. The resident’s care plan, initiated several days prior, identified a focus on episodes of brief LOC and included interventions such as assessing the resident, monitoring for further syncopal episodes, monitoring vital signs (V/S) and O2 saturations, notifying the physician for any change of condition, and placing the resident in a supine position with legs elevated. On the morning in question, the resident experienced a first LOC episode in the rehabilitation room while standing at parallel bars during PT. The PTA reported that the LOC lasted about 30 seconds, during which the resident was laid on a fall mat. Another rehab staff member left to look for a nurse but returned stating that no nurse could be found, and no licensed nurse came to evaluate the resident. Despite a BP machine being available in the rehab room, the resident’s V/S were not taken, O2 sats were not monitored, the resident was not placed supine with legs elevated per the care plan, and the physician was not notified. After the resident regained consciousness, the PTA continued the mat program without a nursing assessment or implementation of the care plan interventions. Later that morning, the resident had a second LOC episode while in a wheelchair in his room, witnessed by a family member and a PTA. After the resident briefly lost consciousness and then attempted to vomit, CNA 1 attempted to obtain BP with a wrist monitor but initially could not get a reading and left to call for a licensed nurse. When LN 1 first entered the room, he stated he had just returned from lunch and left without assessing the resident. CNA 1 then obtained a BP reading several minutes later, and LN 1 returned and assessed the resident, who appeared pale, cold to touch, and sweaty. The family member reported this was the second LOC episode that morning and that no nurse had come after the first episode. LN 1 stated he did not receive notification of the first LOC and acknowledged that physician notification after the second episode was delayed by more than 40 minutes. The DON confirmed that the resident’s care plan interventions for LOC, including nursing assessment, monitoring V/S and O2 sats, physician notification, and placing the resident supine with legs elevated, were not implemented during the first episode and were not timely during the second episode, contrary to facility policies on nursing assessment, change of condition, and comprehensive care plans.
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