Change in Condition

Angie Szumlinski News

A recent lawsuit has been filed against 3 nurses, a nursing home, and a management company related to a resident’s death. The resident was admitted on September 29, 2020, and died of a urinary tract infection on October 31, 2020. She was admitted with an elevated white blood count, became lethargic during physical therapy, on October 15 presented with multiple symptoms of infection, and on October 19, 2020, was admitted to hospice. 

Everyone needs to pause and take note, ask the questions. Did this resident come to the center with an infection and if so, did we miss the symptoms? Was our admission assessment thorough? Did the resident exhibit signs and symptoms of infection that we missed, or thought were delirium related? Obviously, there are more questions than answers but at the end of the day, post-acute providers across the country are being sued for not identifying change in condition. The article went on to say that labs were ordered, and the resident’s white blood count was elevated however the physician was not notified. Is that accurate? The jury is out, what is accurate is that 3 nurses are named in a lawsuit related to care. Not a comforting thought! 

So, what are you doing to prevent this from happening in your center? Communication breakdown – it happens. What are your systems to be sure the physician is notified of abnormal lab values? I worked with a physician in a large, inner city post-acute care center who personally called every morning to check on labs that he had ordered. Are your physicians willing to do that? How about your licensed nurses? Have they been provided with training to identify changes in condition? Remember, changes can be subtle. It might be time to have that meeting that you keep putting off. Share this story with your staff, stress the importance of identifying changes in condition, implement a stop and watch tool and SBAR, use your resources! Sure, even when you do everything perfectly, there are no guarantees but why take the chance? If you need additional training resources on change in condition, please go to and click on the resource and education center. Let us protect our residents and protect those who provide the care. Stay well and stay informed!