F0684

D

Failure to Recognize and Report Significant Changes in Condition for Two Residents

Waterloo, Iowa Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and act on significant changes in condition requiring timely physician notification for two residents. For one resident with atrial fibrillation, mild intellectual disability, and dependence on staff for ADLs and transfers, the resident was sent out for a CT scan and returned the same day. Progress notes documented that the paperwork from the scan could not be printed and that staff planned to follow up in a few days for faxed dictation. Later that day, the resident’s guardian called the facility reporting possible abnormal blood clot results in the lungs and requested an update. A nurse assessed the resident, found a low pulse oximetry reading, placed the resident on oxygen until the saturation normalized, and documented that the resident denied breathing or pain issues. The resident was then assisted to a wheelchair and taken to the dining room, with no incident or concerns noted at that time.

Despite the guardian’s report of possible blood clots in the lungs and the documented low pulse ox requiring supplemental oxygen, there was no documented immediate physician notification or initiation of treatment on that day. Two days later, the MDS coordinator received a call from a provider with CT scan results confirming a pulmonary embolism and an order to send the resident to the ED, after which the resident returned on anticoagulant therapy. The medical director later stated he expected the facility to notify the provider as soon as they knew of the pulmonary embolism and confirmed there was a delay in treatment. Staff interviews indicated that the nurse who assessed the resident after the guardian’s call believed he needed to wait for documentation of the PE or a provider call to validate the PE, and another staff member reported it took two days to obtain treatment orders, noting that the DON did not check her voicemail regularly.

For a second resident with intact cognition and diagnoses including paraplegia, seizure disorder, CAD, respiratory failure, and malnutrition, the respiratory therapist documented two separate episodes of unresponsiveness and dizziness during transfers on the same day. In the morning, during a bed-to-wheelchair transfer, the resident reported dizziness, then developed a fixed gaze and became unresponsive to verbal stimuli for about eight minutes, with respirations of 12–14 per minute, before gradually returning to baseline. In the late afternoon, during another transfer with nursing staff present, the resident again developed a blank stare lasting over 15 minutes, with slowed respirations of 7–8 per minute, grayish lips, no response to sternum rub, and nonreactive pinpoint pupils, before suddenly awakening and reporting thirst, dizziness, and hunger. The EHR contained no nursing documentation, assessment, or physician notification related to these unresponsive episodes.

Subsequently, the respiratory therapist discussed the unresponsive episodes with the DON and they agreed to track the resident’s blood pressure during episodes. Later, the therapist documented that the resident reported a history of low blood pressure treated with medication at another facility and experienced dizziness and near-syncope when the head of the bed was elevated, requiring lowering of the bed angle. A blood pressure of 60/40 was recorded after the resident became lightheaded with positional change. Despite this severely low blood pressure and repeated dizziness with position changes, the EHR still lacked nursing documentation, assessment, or physician notification of these events on that date. The care plan, initiated earlier, did not identify or include interventions for orthostatic hypotension or unresponsive episodes during position changes. The facility’s own policy required immediate physician consultation and notification of the resident and representative for significant changes in status, including loss of consciousness, but this was not followed in these instances.