Failure to Ensure Timely Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The facility failed to ensure a timely ambulance transfer for a resident experiencing respiratory distress. On the day in question, the resident, who had a history of acute respiratory failure with hypoxia, sepsis, quadriplegia, and repeated hospitalizations for shortness of breath, repeatedly requested to go to the emergency room due to shortness of breath and not feeling well. Despite the resident's abnormal vital signs—including low blood pressure, elevated heart rate, and low oxygen saturation—the LPN on duty initially called for a routine ambulance instead of 911. The ambulance dispatcher advised the nurse to call 911 due to the resident's critical condition, but the nurse attempted to contact other ambulance companies instead, delaying emergency care. When the EMT arrived approximately 20 minutes later, the resident was found gasping for air with further deteriorated vital signs and required immediate intervention. The EMT noted that the resident was unable to call 911 herself due to her paraplegia. Interviews with other nursing staff, the DON, and the NP confirmed that the facility's policy and standard practice required calling 911 immediately for acute respiratory distress and significant changes in vital signs. The facility's care plan for the resident also specified prompt response to respiratory complications and emergency needs, which was not followed in this instance.