Imperial Healthcare Center

During a review of Resident 1's Nursing Progress Note dated 8/24/2025 at 11:57 p.m., the progress note indicated Resident 1 was alert with episodes of confusion.

During a review of Resident 1's nursing progress notes from 8/20/2025 through 10/25/2025, the progress notes indicated there was no documented entries Resident 1's physician was notified of the resident's new onset of confusion.

The progress notes indicated there was no documented entries a nursing assessment or monitoring was done addressing Resident 1's new onset of confusion.

During an interview on 12/30/2025 at 4:39 p.m., with Resident 1's Attending Physician (AP 1), AP 1 stated he was aware Resident 1's baseline laboratory values were abnormal on 8/19/2025. AP 1 stated it was common for residents to have abnormal laboratory values at baseline. AP 1 stated when laboratory values or a resident's condition changed from baseline, the facility was expected to notify the physician. AP 1 stated Resident 1 was alert and oriented at baseline and new onset confusion represented a change of condition. AP 1 stated on 8/20/2025, he would have wanted to be notified of Resident 1's confusion. AP 1 stated if he had been notified of Resident 1's confusion he would have sent Resident 1 to the emergency room for evaluation immediately.

During a concurrent interview and record review on 12/31/2025 at 10:00 a.m., with Registered Nurse (RN) 1, Resident 1's nursing progress notes dated 8/11/2025 and 8/20/2025, were reviewed. Resident 1's nursing progress note dated 8/11/2025, indicated Resident 1 was alert and oriented upon admission to the facility. Resident 1's nursing progress note dated 8/20/2025 at 9:42 p.m., indicated Resident 1 was alert with confusion upon her return from dialysis. RN 1 stated this was a new onset of confusion for Resident 1 and represented a change of condition. RN 1 stated when a resident experienced a change of condition, the resident should have been assessed, the physician should have been notified, and appropriate follow-up initiated in accordance with the facility's policy and procedure (P&P). RN 1 stated Resident 1's medical records did not indicate there was a documented nursing assessment, physician notification, a SBAR (Situation, Background, Assessment, and Recommendation), or 72-hour monitoring related to Resident 1's new onset of confusion. RN 1 stated Resident 1 was becoming less alert and less oriented, and this change of condition was not addressed with appropriate interventions which could lead to the deterioration of Resident 1's condition.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 12/2016, the P&P indicated the nurse was required to notify the resident's attending physician of a significant change in the resident's physical, emotional, or mental condition, complete a comprehensive assessment, document the change in condition, and implement continuous monitoring for 72 hours or longer as indicated.

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