Failure to Provide Timely Assistance During Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia and recent aspiration events was not provided timely assistance during an episode of respiratory distress. The resident had been admitted with diagnoses including dysphagia and gastro-esophageal reflux disease, and her care plan included monitoring for signs of swallowing difficulty. Despite this, the resident experienced a coughing episode and signs of respiratory distress during an occupational therapy session, where she was being assisted with self-feeding. The occupational therapist observed the resident coughing and mouth breathing, attempted to obtain a pulse oximeter reading without success, and then left the resident alone to seek help from the LPN. Upon the LPN's arrival, the resident was found unresponsive and pulseless. The LPN left the room again to find the Unit Manager, and when they returned, resuscitation efforts were initiated. There was no documentation of the incident in the resident's medical record by the LPN, and the nurse failed to write an order for hospital transfer after speaking with the nurse practitioner. Interviews revealed that staff had been educated to never leave an unresponsive resident and to call out for help, but this protocol was not followed. The Director of Nursing was unaware that therapy was being provided at the time of the incident. The resident was ultimately pronounced dead, with the cause of death listed as hypoxic respiratory failure and aspiration of food.