A nursing home in Iowa may be fined for not addressing the concerns of two certified nursing assistants (CNAs) regarding a resident who later died. On November 27, 2023, the CNAs informed the on-duty nurse that a resident had experienced a significant change in her mental and physical condition. The CNAs had noticed the resident’s oxygen saturation levels had dropped to 63 percent. In addition, her blood pressure had dropped to 79/39.
The nurse instructed the CNAs to place the resident on bottled oxygen. After 20 minutes, the resident’s oxygen saturation was at 92 percent, but she seemed confused and appeared to be in pain. The CNAs again reported their concerns to the nurse, but according to the state inspection report, the nurse did not seem worried or concerned.
A little later, the CNAs checked the resident’s oxygen levels again and they were back down to 72 percent. The nurse told them to turn the resident’s oxygen up to 3L. According to the CNAs, they did so, but the resident’s vital signs did not improve for the rest of their shift.
When the night nurse came on duty at 10 p.m., one of the CNAs informed her of the situation and said the resident needed to go to the hospital. According to the inspection report, the night nurse agreed and the resident was sent to the emergency room at 10:30 p.m. This was four hours after the CNAs had first reported their concerns. The resident died the next day, with the cause of death listed as congestive heart failure.
The nursing home was cited for medication and treatment violations, failure to respond to changes in a resident’s condition, quality of care violations, and failure to meet standards related to competent nursing staff. A state fine of $11,750 has been held in suspension while the Centers for Medicare & Medicaid Services (CMS) considers imposing a federal penalty.
Compliance Perspective
Issue
Facilities must initially develop and implement a baseline care plan followed by a comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Facility staff should be aware of each resident’s baseline status upon admission in order to compare to their current observations, and be able to promptly identify differences that may indicate a change in health status. Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff member who is involved. It is critical to identify potential issues early so that interventions can be applied to prevent a condition from worsening or becoming acute. Staff are expected to know how to identify residents’ changes in conditions, and what to do once one is identified.
Discussion Points
- Review your policies, procedures, and staffing guidelines to ensure they are designed to result in provision of quality care for residents. Review your Facility Assessment as required by F838 to ensure it addresses the needs of all residents based on their individual acuity levels. Update your policies and Facility Assessment as necessary.
- Train staff on their responsibility to provide safe, high quality nursing care, or to provide support services that help meet resident needs. Train staff to create and learn baseline information for residents and to be able to use the information to compare to their current observations to identify slight or obvious changes that may signal the start of a change in condition.
- Periodically audit to ensure staff are following policies for delivering safe, quality nursing care and support services. Ensure your Facility Assessment is current, thoroughly identifies the needs of all residents, and determines the resources required to provide high quality resident care and services. Audit resident care plans to ensure they are regularly followed and updated as needed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
