Failure to Provide Timely and Appropriate Respiratory Care During Acute Distress
Penalty
Summary
A facility failed to provide safe and appropriate respiratory care to a resident with significant respiratory needs, resulting in a deficiency. The resident, a male with diagnoses including heart failure, renal failure requiring dialysis, COPD, and respiratory failure, was admitted with orders for oxygen therapy and inhaled medications. During incontinence care, the resident developed respiratory distress, with oxygen saturation dropping to 66% while on 5 liters of oxygen via nasal cannula. Despite clear signs of distress, including labored breathing, use of accessory muscles, and rapid respirations, there was a delay in nursing intervention and escalation of care. Staff responses were inconsistent and did not align with professional standards or the resident's care plan. The nurse assigned to the resident did not enter the room until several minutes after being notified, and upon assessment, left the resident multiple times to call the physician rather than staying at the bedside. The nurse administered a nebulizer treatment, but the resident's oxygen saturation remained critically low, and the nurse did not immediately call emergency services. Other staff, including the wound care nurse and ADON, were not fully aware of the resident's status or the duration of his distress. The DON was present in the nurse station but did not assess the resident directly, and there was confusion among staff regarding when to call 911 and the use of available respiratory equipment such as a bi-pap machine. Interviews revealed gaps in staff knowledge and adherence to protocols for acute respiratory events. The facility lacked a rapid response policy, and staff were unclear about the threshold for activating emergency services. The resident remained in respiratory distress for approximately 40 minutes before receiving effective intervention with a non-rebreather mask and transfer to the hospital. The failure to promptly recognize and respond to the resident's acute respiratory needs, as well as to follow established care plans and professional standards, led to the identification of a deficiency by surveyors.
Removal Plan
- Notify Medical Director.
- Conduct emergent QAPI meeting.
- Re-educate staff on Professional Standards of Respiratory Care process.
- Provide one-on-one education to LVN A regarding acceptable standards of practice for residents in respiratory distress. Continue weekly education for LVN A for four weeks, monitored for understanding and implementation of knowledge.
- Educate all licensed nursing staff and certified nurse aides regarding acute change in condition including residents experiencing respiratory distress.
- Audit all patients that require respiratory treatment to ensure care plans and standards of practice are updated and followed.
- Educate new staff upon hire and monthly for 3 months on providing respiratory care according to professional standards of practice.
- Contract Respiratory Therapist to conduct ongoing monthly training and education for all licensed nurses to ensure professional standards of practice are followed for respiratory care needs.
- QAPI team to implement best practices including notifying 911 to transfer a resident to the hospital for respiratory distress with oxygen saturation below 70% and prompt immediate interventions and notification of Medical Doctor for any resident showing signs of respiratory distress.
- Monitor all current patients and newly admitted patients that require respiratory care for appropriate treatment and services.