Failure to Monitor and Respond to Change in Condition Resulting in Delayed Treatment
Penalty
Summary
The facility failed to effectively monitor, report, and respond to a significant change in condition for a resident with a history of COPD, lung cancer, and dementia. The resident was admitted with orders for continuous oxygen and was dependent on two staff for transfers and toileting. In the early morning hours, a CNA independently transferred the resident to the toilet using a mechanical lift, during which the resident became acutely short of breath with an oxygen saturation of 53%. It was later discovered that the oxygen tubing had become disconnected, and after reconnection, the resident's oxygen saturation only improved to 87-89% despite increased oxygen flow and administration of an albuterol inhaler. Following this event, the RN attempted to contact a telehealth provider for further medical direction but did not receive a response for 53 minutes. During this time, the resident's oxygen saturation remained unstable, dipping as low as 78%. The RN eventually contacted the on-call provider, who gave orders for comfort medications and to maintain high-flow oxygen. There was no documented monitoring of the resident's symptoms or vital signs for approximately three hours between the initial incident and the eventual transfer to the hospital. Interviews revealed that care assistants provided only verbal updates, and the family was not kept informed of the resident's ongoing condition during this period. The resident was ultimately transferred to the hospital after continued hypoxia and respiratory distress, where she was admitted under pulmonary critical care and later passed away. The facility's telemedicine policy required prompt physician contact in the event of a change in condition, and both the DON and the on-call provider stated that the delay in contacting a provider was inappropriate. The lack of timely monitoring, documentation, and communication with both medical providers and the family contributed to the delayed medical intervention.