Minnesota Nursing Home Blamed in Resident’s Death
Failure to recognize a significant and life-threatening deterioration in a resident’s condition, and using equipment without a physician’s order and without training on how to use such equipment may indicate a systemic problem regarding the competency level of nursing staff, and result in the submission of false claims due to providing substandard quality of care
Compliance Perspective – Deterioration of a Resident’s Condition
Policies/Procedures: The Compliance and Ethics Officer with the Administrator will review policies and procedures involving protocols for responding to significant changes in the condition of a resident,for obtaining a physician’s orders before using new equipment or devices on a resident, and for ensuring staff competency in using the new equipment.
Training: The Compliance and Ethics Officer with the Director of Nursing will ensure that staff are trained to respond in a timely manner to significant changes in a resident’s condition. Staff will also be trained on the protocol requiring physician’s orders before using new equipment on a resident and trained on how to operate and use equipment and devices.
Audit: The Compliance and Ethics Officer should personally conduct an audit to ensure that staff are not using any equipment or devices without a physician’s order and without having been trained on how to use such equipment or devices.
State investigators found a Minnesota skilled nursing care and rehabilitative services provider responsible for a resident’s death when it failed to seek emergency medical attention for a resident. The resident’s condition deteriorated due to being improperly positioned with a feeding tube in a special chair.
The resident was placed in the V-shaped chair that was intended to provide comfort and ease pain by allowing the resident’s head and thighs to be elevated. However, the resident repeatedly slid down and became “scrunched up”in the chair causing a need for the resident to be repositioned. The nursing home had not obtained a physician’s order for the chair nor did it have a policy for its use. Staff had also not been trained on how to properly use the chair.
When staff members discovered the resident with his shirt saturated with feeding formula from vomiting, his lungs sounded congested and his pulse,blood pressure, and respiratory rate were elevated. The resident became lethargic, cold to the touch, with shallow breathing. A nurse documented his condition as “fluid overload.”
Although several staff members noted continued significant change in the resident’s condition, his vital signs were not re-checked, and no physician was notified. The resident died 3½ hours after the nursing home staff first became aware of a change in the resident’s condition.
The resident’s physician told state investigators that running the feeding tube while the resident was in the special chair could increase abdominal pressure and cause vomiting which would increase the risk of food being regurgitated and aspirated into the lungs.
