Failure to Assess and Notify Physician After Change in Resident's Breathing
Penalty
Summary
A deficiency occurred when a nurse failed to further assess a resident after observing a change in breathing during an overnight shift. The resident, who had multiple diagnoses including a right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and a history of cerebral infarction, was noted to be making coughing-type noises while breathing during rounds. Despite this observed change, the nurse did not conduct a further assessment or document the observation in the resident's progress notes. Additionally, the resident's physician was not notified of the change in condition, which was contrary to the facility's policy requiring physician notification and documentation when there is a change in a resident's status that may require new treatment.