Failure to Notify Provider and Document Resident's Respiratory Decline
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including heart failure, COPD, chronic kidney disease, and cirrhosis, received care and treatment in accordance with professional standards of practice. On the day in question, the resident exhibited a low oxygen saturation of 88% and was experiencing shortness of breath. The LPN on duty applied 2 liters of oxygen but did not document the resident's O2 saturation or conduct a full assessment of the resident's condition prior to the resident being transported to a scheduled doctor's appointment. Furthermore, the LPN did not notify the resident's physician or nurse practitioner about the low oxygen saturation and respiratory distress. Interviews with facility staff, including the transportation driver, MDS coordinator, and DON, confirmed that there was no documentation of the resident's clinical condition prior to transport and that the physician or nurse practitioner was not informed. The lack of documentation and failure to communicate the resident's deteriorating condition to the appropriate medical provider resulted in the resident being sent to the hospital, where he was found to be in fluid overload and continued to experience respiratory distress.