Failure to Provide Safe and Timely Respiratory Care Resulting in Resident Death
Penalty
Summary
A resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced a critical event due to the facility's failure to provide safe and appropriate respiratory care. The resident had a physician's order for continuous oxygen at 3.0 liters per minute via nasal cannula. Over the course of several shifts, the resident's oxygen concentrator was not functioning, and staff relied on portable oxygen tanks, some of which were empty or unavailable. Multiple staff members, including LPNs and nurse aides, failed to assess the resident's respiratory status, obtain vital signs or oxygen saturation levels, or notify the nursing supervisor and provider of the resident's ongoing shortness of breath and equipment issues. Communication breakdowns occurred between shifts and among staff. Nurse aides reported the resident's shortness of breath to the charge nurse, but the charge nurse did not assess the resident or escalate the issue to the supervisor or provider. The nursing supervisor and nurse practitioner were not made aware of the resident's deteriorating condition until the resident was in acute distress. Staff also failed to ensure the availability of functioning oxygen equipment, as all portable tanks on the unit and the emergency cart were found empty when urgently needed, requiring staff to retrieve tanks from another floor. The lack of timely assessment, failure to monitor and document the resident's condition, and inadequate communication and escalation of the resident's change in status resulted in the resident's condition deteriorating to acute respiratory arrest and ultimately death. The facility did not follow its own policies regarding change of condition and oxygen supply management, which required immediate assessment, documentation, and notification of the provider and supervisor in the event of respiratory distress or equipment malfunction. These failures led to a finding of Immediate Jeopardy.