Failure to Provide Timely Respiratory Care and Communication of Change in Condition
Penalty
Summary
A deficiency occurred when a resident with significant respiratory and cardiac conditions, including acute on chronic respiratory failure, atrial fibrillation, and heart failure, was not provided timely and appropriate respiratory care. The resident was dependent on staff for most activities of daily living and had active orders for oxygen therapy. On the night of the incident, the resident became disconnected from her oxygen concentrator, resulting in severe hypoxia and acute respiratory distress. Despite the resident and her roommate activating the call light and requesting a nurse, the certified nursing assistant (CNA) who responded did not effectively communicate the resident's request or recognize the change in condition that required immediate nursing intervention. Multiple failures in communication and recognition of the resident's deteriorating condition were documented. The CNA did not notify the registered nurse (RN) that the resident needed a nurse, and another CNA who later assisted also did not report the change in condition, relying on the first CNA's assurance that the nurse had been informed. The RN only discovered the resident's distress by chance when entering the room to change the oxygen tubing as per routine orders. Upon assessment, the RN found the resident with blue fingertips, shallow breathing, and a pulse oximeter reading in the 50s. Emergency services were called, and the resident was transferred to the hospital, where she was diagnosed with acute hypercapnic respiratory failure and treated for severe hypoxia and heart failure exacerbation. Interviews with staff and residents confirmed that the CNAs did not recognize or report the resident's acute change in condition, and the nurse was not made aware of the urgent need for assessment until she entered the room for unrelated reasons. Facility records and disciplinary documentation indicated that the CNA involved was suspended pending investigation for failing to notify the charge nurse of the change in condition, and that there was a lack of adherence to facility policy regarding notification of significant changes in resident status.