Failure to Provide Timely and Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate and timely respiratory care and treatment for a resident with a complex medical history, including COPD, asthma, and recent pneumonia. The resident experienced a decline in respiratory status, exhibiting symptoms such as shortness of breath, abnormal lung sounds, and decreased oxygen saturation. Despite an order for oxygen at 1-5 liters per minute, staff increased the oxygen to seven liters without additional interventions or new orders, and there was no documented evidence of further assessment or monitoring of the resident's respiratory or neurological status for a two-day period. The resident's care plan included interventions for COPD, such as monitoring for signs of respiratory insufficiency and infection, but there was no documentation reflecting the use of oxygen or updates to the plan of care after the resident's respiratory decline. Progress notes indicated that the resident had labored breathing and low oxygen saturation, yet no new treatments or orders were implemented by the nurse practitioner after these findings. The medication administration record showed that oxygen was administered above the ordered range for five days, with no corresponding documentation of physician notification or adjustment of the care plan. Ultimately, the resident developed new onset shortness of breath and chest pain, with abnormal lung sounds and pitting edema, leading to a transfer to the hospital where the resident was admitted for acute respiratory failure with hypoxia, acute exacerbation of COPD, and pneumonia. Interviews with staff confirmed concerns about the resident's status and a lack of timely intervention or escalation of care prior to the hospital transfer.