Delayed Nursing Assessment and Intervention for Acute Respiratory Change
Penalty
Summary
A deficiency occurred when staff failed to provide timely assessment and intervention for a resident who experienced a significant change in condition. The resident, who had diagnoses including anxiety, depression, respiratory failure, and metastatic cancer, was observed by a family member to be breathing abnormally and complaining of being cold. The family member alerted a CNA and requested a nurse, but the LPN on duty delayed responding for approximately 45 minutes. During this time, CNAs measured the resident's temperature at 102°F and oxygen saturation at 75% on room air, then initiated supplemental oxygen and notified the LPN. The LPN arrived later, assessed the resident, and administered medications as ordered, but the delay in assessment and intervention was documented by both staff and family accounts. The resident's care plan did not include respiratory-related interventions, despite the resident's history and acute symptoms. Documentation showed that the LPN recorded improved oxygen saturation after intervention, but EMS later found the resident's oxygen saturation had dropped again, requiring increased oxygen support. Facility policy required prompt nurse assessment and physician notification for changes in condition, but this was not followed in this instance, as confirmed by staff interviews and review of the facility's change of condition monitoring process.