Failure to Assess and Monitor Respiratory Status Following Resident Distress
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with a history of respiratory failure, COPD, obstructive sleep apnea, type 2 diabetes, and heart failure. Upon admission from the hospital, the resident arrived hypoxic, requiring high-flow oxygen and BiPAP, with persistent low oxygen saturation and increased work of breathing. Despite these critical symptoms, there was no documentation of a comprehensive respiratory assessment or clear orders for the use of CPAP or BiPAP in the medical record, and the admission assessment did not indicate the use of these devices. On the morning of the incident, the resident requested removal of their CPAP and assistance with oxygen via nasal cannula, reporting difficulty breathing. A CNA assisted with this request and reported the resident's oxygen saturation as 90-91%. However, there was no evidence that a licensed nurse performed a follow-up assessment after the resident reported respiratory distress. The resident was later found unresponsive, with signs of lividity and rigor mortis, and was pronounced deceased. The medical record also showed that as-needed inhaled medications for shortness of breath were not administered or documented as given. Interviews with staff revealed uncertainty regarding the oxygen flow rate and a lack of clarity about the resident's respiratory status prior to being found unresponsive. The facility's Regional Clinical Director acknowledged that a follow-up nursing assessment should have occurred after the resident reported difficulty breathing. The failure to assess and monitor the resident's respiratory status after a report of distress directly contributed to the deficiency.