Failure to Assess Lung Sounds and Intervene for Resident with Respiratory Distress
Penalty
Summary
Facility staff failed to assess a resident's lung sounds before and after administering nebulizer treatments, as required by professional standards and facility policy. The clinical record for the resident, who had a history of chronic obstructive pulmonary disease (COPD), heart failure, chronic respiratory failure with hypoxia, and other comorbidities, lacked documentation of lung sound assessments associated with both scheduled and as-needed nebulizer treatments. This omission was confirmed through clinical record review, staff and ARNP interviews, and was acknowledged by the Director of Nursing. The resident experienced increasing shortness of breath (SOB) on exertion, at rest, and when lying flat over several days, as documented in the Treatment Administration Record and nursing notes. Despite these symptoms, there was no evidence that staff intervened appropriately or communicated the changes in the resident's condition to the physician in a timely manner, as required by facility policy. Family members also reported raising concerns about the resident's worsening breathing, which they felt were not adequately addressed by the facility. On the night of the acute event, the resident exhibited significant respiratory distress, including low oxygen saturation, audible wheezing, and diaphoresis. Nursing staff administered PRN nebulizer treatments and increased supplemental oxygen, but documentation continued to lack pre- and post-treatment lung sound assessments. The resident was eventually transferred to the hospital, where she was diagnosed with parainfluenza, acute on chronic respiratory failure, and COPD exacerbation, and subsequently passed away. Interviews with staff and review of facility policy confirmed that the expected standard of care was not met regarding assessment and timely intervention for changes in respiratory status.