Failure to Provide Care Consistent with Professional Standards During Respiratory Emergency
Penalty
Summary
A resident with a history of COPD and metastatic lung cancer experienced a medical emergency involving severe respiratory distress and critical hypoxia. During this event, licensed nursing staff failed to perform a physical assessment by not listening to the resident's lung sounds or assessing for the use of accessory muscles. The staff did not administer oxygen appropriately, attempting to decrease the oxygen flow despite the resident's low oxygen saturation levels, and failed to provide Albuterol as ordered by the physician. Additionally, the staff did not document the resident's oxygen saturation levels throughout the emergency, nor did they ensure prompt transfer to the hospital, with a delay of approximately 50 minutes from the discovery of the resident's critical condition to contacting emergency services. The nursing staff also did not immediately notify the resident's physician upon discovering the critical condition, with documentation showing a delay of about 50 minutes before the physician was contacted. There was a lack of documentation regarding the nursing interventions implemented during the emergency. The facility's policies and job descriptions required timely assessment, intervention, and documentation, including monitoring and reporting changes in condition, administering medications as ordered, and documenting all care and resident responses. These requirements were not met during the incident. Interviews with facility staff, the DON, and the resident's physician confirmed that the actions taken were inconsistent with professional standards of nursing care and the resident's individualized care plan. The resident was ultimately transferred to the hospital in critical condition, where she required intensive interventions, including intubation and ICU admission. The failure to follow established protocols and provide care consistent with professional standards directly contributed to the severity of the resident's condition during the emergency.