Delayed Physician Response to Respiratory Distress and Chest Pain
Penalty
Summary
A resident with a recent history of hospitalization for breathing difficulties experienced chest pain and respiratory concerns over a period of several days. Nursing progress notes indicated that concerns about chest pain were raised by respiratory therapy and the unit manager, and a call was placed to the physician call center. However, there was a significant delay in obtaining new physician orders, with no new orders documented until 19 hours after the initial concern. During this time, the resident continued to exhibit symptoms such as low oxygen saturation, a wet/loose cough, and pleural rub sounds, with oxygen saturation levels dropping as low as 86% on prescribed oxygen. Despite ongoing communication among staff regarding the resident's deteriorating condition, including further drops in oxygen saturation and continued respiratory distress, there was no timely follow-up from the physician. The resident's condition worsened, and he was eventually transferred to the hospital by ambulance after his oxygen saturation fell to 79% while on oxygen. Hospital records confirmed the resident was admitted for acute on chronic hypoxic respiratory failure and other related complications.