Failure to Ensure RN Assessment After Resident’s Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident experiencing a change in condition was assessed by an RN in accordance with professional standards and facility policy. The RN job description required RNs to assess residents for changes in status, notify the physician and family or representative, and document accordingly. The resident involved had diagnoses including hypertension, hyperlipidemia, and a cognitive communication deficit. On the day of the incident, a caregiver notified an LPN that the resident needed a nurse. When the LPN entered the room, the resident had labored, mouth breathing, dry mucous membranes, low blood pressure, and an oxygen saturation that could not be obtained. The LPN documented that the supervisor was notified, that the supervisor came to assess the resident and instructed the LPN to call 911, and that the LPN notified the resident’s sister and on-call provider. The LPN further documented that the resident was breathing with a faint pulse when EMTs arrived, and that the resident stopped breathing as EMTs prepared to transfer the resident, at which point CPR was initiated and continued until the resident was pronounced expired. Review of the clinical record showed no documentation that an RN assessed the resident after the change in condition was identified. In an interview, the Director of Nursing confirmed that the facility failed to ensure residents were provided appropriate treatment and care in accordance with professional standards of practice for this resident.
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