Failure to Recognize and Respond to Choking and Respiratory Distress
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies to recognize and respond to an emergent situation involving a resident with a history of stroke, right-sided paralysis, chronic respiratory failure with hypoxia, and trouble swallowing. The resident, who was a full code, experienced a choking episode that progressed to respiratory distress, with oxygen saturation dropping to 64% and a heart rate of 149-150 beats per minute. Despite these critical changes, staff did not perform a thorough assessment, such as listening to lung sounds, and did not initiate CPR when the resident became pulseless and unresponsive. The non-rebreather mask used was not inflating, and the resident's oxygen saturation only improved slightly after being switched back to an oxygen tank at a higher flow rate. Video surveillance and interviews confirmed that the resident was brought back to her room in a wheelchair with her head down and chin to chest, appearing very pale and not breathing when paramedics arrived. Paramedics found the resident in cardiac arrest with no CPR having been performed by staff. The facility's policy required continuous monitoring and appropriate interventions for significant changes in condition, but these were not followed, resulting in the resident's death. The failure to provide competent nursing care and initiate life-saving interventions led to the declaration of Immediate Jeopardy.