Failure to Assess and Intervene for Resident with Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced shortness of breath and did not receive timely assessment or intervention from nursing staff. The resident had a physician's order for continuous oxygen and a care plan directing staff to monitor for respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. On the day of the incident, 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 did not observe the nurse assess the resident at either time. The charge nurse acknowledged being notified by the nurse aides about the resident's symptoms and directed them to bring portable oxygen tanks due to a malfunctioning concentrator, but did not personally check on or assess the resident, nor did she take vital signs or oxygen saturation levels. The nursing supervisor was not informed of the resident's condition until later in the morning, at which point the resident was found in severe respiratory distress. The nurse practitioner and supervisor responded immediately, but the resident became unresponsive and, despite CPR and emergency services intervention, was pronounced deceased. Facility policy required that any change in a resident's condition be identified and addressed promptly, with the LPN responsible for collecting data and administering treatments, and the RN/supervisor to be notified for further assessment and provider notification. In this case, the failure of the charge nurse to assess the resident and notify the supervisor or provider in a timely manner led to a lack of appropriate intervention for the resident's acute respiratory symptoms.