Failure to Provide Safe and Appropriate Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide respiratory care consistent with standards of practice for a resident with chronic obstructive pulmonary disease (COPD). Staff did not consistently administer oxygen as ordered by the physician, with multiple instances documented where the resident received either less or more oxygen than prescribed. Additionally, staff failed to notify the physician of significant changes in the resident's respiratory status, including reduced oxygen saturation levels, diminished lung sounds, shortness of breath, and the presence of cough. These changes were repeatedly documented in the resident's records without evidence of timely physician notification. The resident's care plan addressing oxygen usage and respiratory care was not created in a timely manner, being completed 24 days after admission and 11 days after the completion of the admission Minimum Data Set (MDS). Throughout the resident's stay, there were multiple documented episodes of respiratory distress, low oxygen saturation, and other symptoms such as cough and diminished lung sounds. Despite these findings, staff did not consistently assess, document, or communicate these changes to the physician as required. Interviews with staff revealed a lack of clarity regarding the process for physician notification and change of condition, with some staff relying on informal methods such as sticky notes rather than direct communication. The facility did not provide policies regarding change of condition procedures or physician notification when requested. The resident ultimately experienced severe respiratory distress, became cyanotic, and was sent to the emergency department, where cardiac arrest occurred. Interviews with staff, other residents, and the physician confirmed that the resident had ongoing respiratory issues and that appropriate notification and care planning were not consistently performed.