F0684

J

Failure to Recognize and Report Resident’s Deteriorating Condition and Hypotension

League City, Texas Survey Completed on 03-19-2026

Penalty

Fine: $18,860

Summary

The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices when there was a clear change in condition. The resident was an adult male with Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a physician. On the day in question, a medication aide documented hypotensive blood pressure readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., but there was no corresponding change-in-condition assessment completed that day, and the low readings were not effectively communicated to the licensed nurses responsible for his care.

Throughout that day and night, multiple staff observed and described significant deviations from the resident’s usual baseline without ensuring appropriate nursing assessment and provider notification. A CNA working the day shift reported that the resident, who normally liked to play on his computer, slept most of the day and did not eat breakfast or lunch except for one cup of vanilla pudding; he stated he told the floor nurse but could not recall who it was or what action was taken. Another CNA on the night shift stated the resident was “out of it,” barely spoke, slept most of the shift despite usually staying up late, had heavy breathing, and only nodded his head with eyes closed in response to questions; she reported communicating these concerns to the night nurse and checking on him several times. The medication aide on the 2:00 p.m. – 10:00 p.m. shift acknowledged that the resident’s blood pressure was low and that he held the resident’s blood pressure medication, but he could not clearly identify which nurse he informed or what the nurse’s response was.

Licensed nurses on both shifts reported that they were not made aware of the resident’s low blood pressure readings or his refusal of meals. The day-shift LVN stated she received no notifications from CNAs or medication aides that the resident had low blood pressure or had not eaten, and she indicated she would have contacted the provider if she had known of a systolic reading of 86. The night-shift LVN stated she checked on the resident several times, received nods or brief verbal responses, and did not recognize a change in behavior; she also stated she was told by a CNA that the resident had not eaten breakfast or lunch but believed that CNA had already informed the day nurse. Neither LVN had knowledge of the documented hypotensive readings. The following morning, another LVN found the resident barely responsive, clammy, with an untouched breakfast tray, a blood pressure of 75/54, and unresponsiveness to a sternal rub, at which point EMS was called and the resident was sent to the hospital. Hospital staff and the primary medical doctor later described the resident as having been deteriorating for hours, with findings including blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and he required multiple rounds of CPR.

The facility’s own policy titled “Change in Resident Condition” required that when there was a significant change in a resident’s physical, mental, or psychosocial status, the medical provider should be contacted. The DON stated that when the medication aide identified low blood pressure, he should have notified the nurse immediately, and that CNAs and medication aides were expected to provide verbal updates to nurses, who in turn were responsible for notifying the provider, completing documentation, and ensuring oversight. In this case, despite documented hypotension, decreased intake, increased sleepiness, and altered responsiveness over many hours, there was a breakdown in communication and follow-through: the low blood pressure readings were not effectively reported to the LVNs, no change-in-condition assessment was completed on the day of the abnormal readings, and the provider was not contacted about the resident’s change in condition until the following morning when he was found unresponsive and required emergency transfer.

The primary medical doctor later stated that the resident was found unresponsive to a hard sternal rub with low blood pressure and vomit around his mouth, and that he appeared to have been deteriorating for hours. A hospital registered nurse reported that the resident was admitted due to unresponsiveness, required three rounds of CPR because his heart stopped, and imaging and cultures showed an infarct and blood infection. A hospital nurse practitioner stated that the resident was positive for a blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and that his unresponsiveness was caused by multiple factors. The resident’s family member reported that his mind had been very sharp despite prior stroke-related mobility issues and expressed gratitude that the LVN who found him unresponsive returned to check on him, stating that this likely saved his life. These findings collectively demonstrate that staff did not act in accordance with the resident’s care plan and facility policy regarding timely recognition, assessment, and reporting of a significant change in condition.