Failure to Notify Physician of Change in Condition for Resident with Respiratory Distress
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a significant change in condition for a resident with complex medical needs, including respiratory failure, pneumonia, tracheostomy, and recent COVID-19 diagnosis. The resident, who was a full code and dependent on staff for all activities of daily living, returned from a hospital stay with new orders for antibiotics and continued to require oxygen and suctioning. Documentation showed that the resident experienced labored breathing and fluctuating oxygen saturations, but there was no evidence that the physician was notified of these changes during the night prior to the resident's death. Nursing and respiratory therapy staff noted increased secretions, labored breathing, and the need for frequent suctioning. Despite these observations, the nurse on duty relied on input from the respiratory therapist, who was contacted via Facetime and indicated that the resident's condition appeared to be her baseline. The nurse did not escalate the situation or seek further assistance, and there was no documentation of physician notification regarding the resident's respiratory distress. The resident's family was not informed of the labored breathing, and the physician later confirmed she was not contacted during the critical period. Interviews with staff revealed uncertainty and lack of familiarity with the resident's baseline condition, as well as a lack of clear communication and documentation regarding the resident's respiratory status. The facility's policy required prompt notification of the physician and responsible party for significant changes in condition, but this was not followed. The resident ultimately experienced respiratory failure and was transported to the hospital, where she passed away. The deficiency was substantiated by review of medical records, staff interviews, and facility policy.