Failure to Assess and Respond to Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when staff failed to fully assess and promptly treat a resident who was observed to be in respiratory distress. The resident, who had a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and respiratory failure, was on hospice care and dependent on oxygen and CPAP therapy. On the morning of the incident, the resident was found sitting on the edge of the bed, appearing bluish/gray, with labored, rapid breathing and grunting sounds, while holding a CPAP mask and receiving oxygen via nasal cannula at 3 liters per minute. Despite being alerted by both a CNA and another resident, the nurse did not perform a full assessment or take vital signs, and instead left the room to notify the DON and continued with medication administration for other residents. The nurse did not return to the resident's room until after a hospice nurse had already entered and begun assessing the resident. The hospice nurse found the resident to have significant dyspnea, diminished lung sounds with crackles, and an oxygen saturation of 85%. She recommended increasing oxygen flow and inquired about the last administration of Morphine for comfort. The nurse reported that Morphine had last been given several hours earlier and that the resident had refused a subsequent dose. The nurse then increased the oxygen flow and applied the CPAP mask, but documentation of a comprehensive respiratory assessment was lacking in the medical record. Facility policies required prompt notification of changes in condition, thorough assessment including vital signs and respiratory evaluation, and documentation of findings and interventions. Interviews with the DON and consulting staff confirmed that the nurse did not follow proper procedures for assessing and responding to a change in condition. The nurse acknowledged not taking a complete set of vital signs and stated that the presence of a surveyor made him nervous, contributing to the incomplete assessment and delay in care.