Failure to Assess and Respond to Resident's Change in Condition Leading to Respiratory Distress
Penalty
Summary
A deficiency occurred when staff failed to assess and appropriately treat a significant change in condition for a resident with multiple complex medical diagnoses, including end stage renal disease, heart failure, and dependence on oxygen therapy. The resident, who was cognitively intact, began experiencing respiratory distress, with oxygen saturation levels dropping to 76% despite being on supplemental oxygen. Staff did not document vital signs in the medical record, did not notify the physician, and did not initiate timely interventions or transfer to a higher level of care, despite the resident's ongoing complaints of shortness of breath and visible distress. Certified nursing assistants and licensed nursing staff reported that they typically only took and documented vital signs if specifically asked, and in this case, vital signs were either not taken or not properly recorded in the electronic medical record. The nurse on duty interpreted the resident's distress as a panic attack, attempted to calm her, and did not escalate care or notify the physician as required by facility policy. The resident's family was called to assist, but upon arrival, found the resident in severe respiratory distress and called 911 themselves. Emergency Medical Services found the resident cyanotic, with a pulse oximetry reading of 50%, and required advanced airway management and intubation en route to the hospital. Facility documentation and interviews confirmed that the care plan did not address the resident's oxygen use or respiratory issues, and there was no evidence that the physician was notified of the resident's deteriorating condition. The facility's change of condition policy required timely communication with the physician and family in the event of significant changes, but this was not followed. The failure to assess, document, and respond to the resident's acute respiratory distress resulted in a delay in emergency intervention and transfer to the hospital.
Removal Plan
- Admin/DON were inserviced by VP of Clinical
- Admin inserviced IDT team
- Current staff inserviced on change of condition and notifying nurse. Change of condition, notifying MD, document vitals, SBAR, head to toe assessment, full set of vitals, and continued vitals.
- Last 30 days of change of conditions in residents have been reviewed to ensure that no other issues have been identified.
- All residents with change of condition reviewing medical records.
- Review of policy and procedures have been completed with MD. Reviewed & updated.
- Initial change of conditions in residents nurse will notify MD and follow MD orders at the time of change of condition.
- Noted change of condition where oxygen levels are below 92%, titrate it up 1L, recheck q 30 mins until O2 can reach 92%, if distress is noted notify MD. If no, change in condition MD is to be notified again. Standing order provided by MD. Being completed by VP of clinical, Director of Nursing, MD, and administrator.
- All working staff have been in-serviced on change of condition policy and procedure. Currently all staff on shift have been in-serviced. Total facility staff in-serviced at 75%. 100% completion will be done. Being Completed by IDT team, DON, administrator, and/or designee by start of next worked shift.
- No staff will work before being in serviced on change of condition. Ongoing - Being completed by IDT team, DON, administrator, and/or designee by start of next working shift.
- A Quality assurance tool was implemented; daily audit of the 24 hour report and dc notices for change of conditions, vitals, dc notes, and MD notification if there is a noted change of condition. Audits to continue daily to ensure that change of condition is documented. Audits complete by: DON/Designee
- Root Cause Analysis completed for Change of Condition