An Iowa nursing home was recently fined after state regulators said it failed to properly report a resident’s worsening health. The facility was fined $325 after state inspectors discovered that staff had not adhered to written policies while caring for a resident during the fall of 2023.
According to documents from the Iowa Department of Inspections, Appeals, and Licensing, the resident experienced a decline in health after testing positive for COVID-19 in September 2023. Several days after testing positive, his oxygen levels dropped to 85–87 percent.
On October 1, the resident was observed to have a dark skin color and shortness of breath. Staff found that his oxygen level ranged from 73–85 percent. He was sent to the emergency room at a local hospital where he was intubated. He was eventually sent to a larger hospital and admitted to the intensive care unit.
According to the facility’s Change in Resident Physical or Mental Health Condition policy, if staff note a change in a resident’s physical or mental condition they are to communicate that information to the charge person. The charge person should then consult with the director of nursing (DON), administrator, administrator’s designee, and/or primary care or mental health provider.
The resident’s primary care provider had previously indicated that she wanted to be contacted if the resident’s oxygen levels dropped below 90 percent. However, staff failed to inform her of the resident’s change in condition. According to the state inspectors’ report, staff had also failed to notify the DON (the charge person noted in the facility’s policy) and the administrator.
Compliance Perspective
Issue
Facility staff should be aware of each resident’s current health status and regular activity, and be able to promptly identify changes that may indicate a change in that health status. Once identified, staff should demonstrate effective actions to address the change in condition. The attending practitioner must be immediately notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident’s condition. 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 condition, and what to do once one is identified.
Discussion Points
- Review your policies and procedures regarding identifying and documenting residents’ initial baseline status upon admission and comparing that with their current status to identify a change of condition. Update your policies, as necessary.
- Train staff to record baseline status information for residents upon admission and to use that information to compare vital signs, behavior, and activity levels each day to identify slight or obvious changes that may signal the start of a change in condition. A program titled Identifying and Understanding a Resident’s Change of Condition is available in Med-Net Academy Prime, Clinical Category, and also in a CE version in Prime or in the MNA Store.
- Periodically audit to ensure staff are following policies regarding resident change of condition. Also audit to ensure staff know to whom they are to report change of condition observations and concerns. Audit a sample of medical records for residents transferred to the ER or admitted to the hospital to determine that timely notification of changes in condition occurred. Provide additional education for staff where needed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
