Failure to Timely Identify and Treat Change in Respiratory Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and respond to a significant change in a resident's respiratory condition, resulting in actual harm. The resident, who was a full code, non-verbal, and had a tracheostomy, exhibited labored breathing, tested positive for COVID-19, and was being treated for pneumonia. Despite these risk factors and a history of respiratory complications, the LPN on duty did not notify the physician about the resident's labored breathing or the absence of secretions during suctioning. The LPN, unfamiliar with the resident, relied on information from a respiratory therapist (RT) via Facetime, who indicated the resident's breathing was at her baseline, and did not escalate care or seek further assistance until the resident was found unresponsive. The resident's medical record showed multiple complex diagnoses, including respiratory failure, pneumonia, encephalopathy, and tracheostomy status. Documentation revealed that the resident had previously required frequent suctioning for thick secretions and had a history of mucous plugs, which could cause acute respiratory distress. On the night of the incident, the LPN noted labored breathing and minimal secretions during suctioning but did not recognize these as signs of a potential mucous plug or acute deterioration. The RT, who was off-site, advised that the resident's condition was normal based on prior experience, but had not personally assessed the resident that day. There was no evidence in the records that labored breathing was normal for this resident, and the physician later confirmed she was not contacted about the change in condition. The facility's policy required prompt notification of the physician and responsible party for significant changes in a resident's condition. However, the LPN did not notify the physician or seek additional help until the resident was found without vital signs, at which point CPR was initiated and the resident was transferred to the hospital. Hospital records indicated the resident was admitted for acute on chronic respiratory failure with hypoxia, with findings suggestive of a possible mucous plug and severe sepsis. The resident ultimately passed away at the hospital. Interviews with staff and review of documentation confirmed that the failure to recognize and act upon the resident's change in respiratory status, and the lack of timely physician notification, directly contributed to the deficiency.