Failure to Timely Notify Provider of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure, COPD, CHF, and dependence on supplemental oxygen reported shortness of breath to staff, but the provider was not notified until approximately three hours later. The resident's care plan required staff to monitor for signs of respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. Despite these directives, nurse aides reported the resident's shortness of breath to the charge nurse shortly after the start of the shift and again later in the morning, but the charge nurse did not assess the resident, take vital signs, or notify the provider or nursing supervisor at that time. The charge nurse was informed by the previous shift that the resident's oxygen concentrator was not functioning and that portable oxygen was being used. Although the nurse aides followed protocol by reporting the resident's symptoms, the charge nurse only instructed them to bring additional portable oxygen tanks and did not perform a respiratory assessment or further evaluate the resident's condition. The nursing supervisor was on the unit during this period but was not made aware of the resident's complaints or the issues with the oxygen equipment until a critical event occurred. The situation escalated when the resident began calling out for help, stating they could not breathe. At this point, the nursing supervisor and a nurse practitioner responded immediately, assessed the resident, and initiated emergency interventions, including calling 911 and performing CPR. Despite these efforts, the resident was pronounced deceased. Interviews confirmed that the provider and nursing supervisor were not notified of the resident's change in condition in a timely manner, contrary to facility policy and the resident's care plan.