Failure to Assess Respiratory Status Following Change in Condition
Penalty
Summary
The facility failed to assess the respiratory status of a resident who exhibited notable respiratory changes, including increased anxiety, a persistent dry cough, and behaviors such as repeatedly wiping his tongue. Despite these symptoms, the assigned LPN did not perform a lung assessment or obtain an oxygen saturation level, only taking vital signs, which were not documented. Later, another LPN found the resident to be lethargic and pale, with an oxygen saturation of 78%, and the resident became unresponsive, requiring emergency intervention and transfer to the hospital. Staff interviews revealed uncertainty about protocols for respiratory assessment, and documentation showed that required assessments and monitoring were not consistently performed or recorded as per facility policy. The resident had a medical history including dysphagia, cerebral infarction, generalized anxiety disorder, gastrostomy, and acute respiratory failure with hypoxia, and was receiving enteral nutrition. Facility policies required respiratory assessments with any change in condition, especially for residents with risk factors such as tube feeding and respiratory diagnoses. However, these protocols were not followed when the resident displayed respiratory changes, resulting in a delay in assessment and medical intervention.