Failure to Timely Assess and Escalate Care for Resident in Respiratory Distress
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate monitoring, thorough assessment, timely notification to a medical provider, and accurate documentation for a resident experiencing a change in condition. The resident, who had a history of acute and chronic respiratory failure with hypoxia, asthma, anoxic brain damage, dysphagia, and was dependent on a mechanical ventilator, began to show signs of respiratory distress. The family noticed abnormal breathing and alerted the RN, who assessed the resident, took vital signs, and administered pain medication, but did not escalate the situation or notify a medical provider at that time. Despite the resident's elevated heart rate and labored breathing, the RN did not reassess the resident or contact the respiratory therapist or physician promptly. Approximately 30 minutes later, the resident's condition worsened, with lips turning blue and continued respiratory distress. The respiratory therapist was called, provided manual ventilation, and the RN eventually called 911. Documentation was inconsistent, with missing or unclear vital signs, incomplete progress notes, and medication administration records not reflecting the administration of ordered respiratory treatments. Interviews with staff revealed a lack of clear communication and timely intervention. The Director of Nursing stated that the expectation would have been to escalate the situation and contact the medical provider and respiratory therapist for a ventilator-dependent resident with an elevated pulse and respiratory distress. However, this did not occur, and there was no evidence of a facility investigation into the incident at the time of the survey. Facility policy required prompt notification of changes in condition, especially life-threatening situations, but this protocol was not followed in this case.