Delay in Emergency Response and Incomplete Documentation Following Resident's Acute Change in Condition
Penalty
Summary
The facility failed to provide timely emergency medical intervention for a resident who experienced an acute change in condition. The resident, who had multiple significant diagnoses including rib fractures, vertebral fractures, dysphagia, severe malnutrition, and acute thrombosis, was noted to be cognitively impaired and at risk for altered nutrition and hydration. On the day of the incident, the resident was observed to be eating normally during breakfast and lunch, but was later found by a CNA to be wheezing and with glazed eyes. The CNA alerted the LPN and ADON, who responded to the change in condition. Despite the resident exhibiting shortness of breath, audible crackles, and a dangerously low oxygen saturation of 65%, there was a delay in calling Emergency Medical Services (EMS). Documentation revealed uncertainty and lack of clarity regarding the exact times of the change in condition, when EMS was called, and when the physician was notified. There was no documentation of when the change began, no SBAR form completed, and no evidence that the physician or on-call provider was notified prior to EMS being called. The facility's own policy requires notification of the physician or nurse practitioner in the event of a significant change in condition, except in a medical emergency. EMS records and staff interviews indicated that EMS was called approximately one hour after the initial change in condition was noticed. Upon EMS arrival, the resident was unresponsive, tachypneic, and had evidence of aspiration. The resident was transferred to the hospital, where she later expired. The lack of timely EMS notification and incomplete documentation contributed to the delay in treatment for the resident.