F0684

D

Failure to Perform Timely and Ongoing Assessments After Change in Condition

Wakarusa, Indiana Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely and thorough assessments following a change in condition for a resident with end-stage renal disease on dialysis and dementia. The resident’s care plan required attendance at dialysis three times weekly and monitoring for pain, with staff to observe for signs and symptoms of pain and notify the physician of uncontrolled pain. On a dialysis day, the dialysis RN documented that the resident experienced an unusual drop in blood pressure requiring extra fluids to maintain systolic pressure above 100, was more restless and agitated than usual, wanted to stop treatment early, and raised concern for developing sepsis, instructing that the resident be seen by a nurse or doctor to rule out sepsis. The dialysis communication form reflected these concerns, but upon the resident’s return, there was no documentation that the unit manager or day-shift nurse reviewed the dialysis form, performed an assessment, or notified the NP or physician of the dialysis staff’s concern for sepsis.

Later that same day, the evening-shift LPN, who had not been informed that dialysis was stopped early and had not seen the dialysis communication form, found the resident refusing supper and complaining of abdominal pain. The LPN assessed the resident, attempted repositioning without relief, administered Tylenol per orders, and notified the NP, who ordered a STAT abdominal x-ray and instructed that the resident be sent to the hospital if symptoms persisted. Progress notes documented the resident repeatedly calling out with abdominal pain and stating she could hardly breathe, with a rounded, soft abdomen, right upper quadrant tenderness, normal bowel sounds, and a bowel movement earlier that day. After the abdominal x-ray showed no acute abdominal issues, the NP ordered close monitoring and transfer to the hospital if fever or worsening pain developed. The last documented observation that night indicated the resident was sleeping, easily arousable, and without obvious signs of pain.

Following this documented change in condition and initiation of an SBAR form, the facility’s process required follow-up assessments every shift for 72 hours, but the record contained no such follow-up assessments after an early-morning note indicating the resident was resting without complaints of stomach pain. There were no further assessments or progress notes from the early morning of the next day until two days after the initial event, when another SBAR documented severe abdominal pain, with the resident yelling out and reporting increased lower abdominal and severe right lower abdominal pain, prompting transfer to the hospital. A nurse who worked the intervening day shift reported being told the resident had stopped dialysis early due to feeling sick and nauseous and had decreased appetite for several days, but she did not perform an assessment because there were no further reports of abdominal pain and the abdominal x-ray had been negative. The absence of documented follow-up assessments and failure to act on the dialysis center’s sepsis concern and early termination of dialysis constituted the failure to ensure timely assessments following a change in condition.