Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, falls, and anxiety disorder, who was admitted with wheezing, did not receive safe and appropriate respiratory care as needed. The resident had physician orders for nebulizer treatments for shortness of breath or wheezing, but there was no comprehensive care plan developed for respiratory care, and interventions were not documented. The care plan for respiratory function was initiated and resolved on the same day without interventions, and documentation related to respiratory monitoring and effectiveness of treatments was lacking throughout the resident's stay. Multiple records, including 24-hour reports and medication administration records, showed that the resident's respiratory status was not consistently monitored as ordered by the physician. Nursing notes failed to document the effectiveness of nebulizer treatments or ongoing assessment of the resident's respiratory condition. Interviews with staff revealed that nurses often left the resident unattended during nebulizer treatments, did not always document vital signs or treatment effectiveness, and did not consistently communicate changes in the resident's condition to the physician. The Director of Nursing confirmed that while there was a policy for nebulizer administration, there was no specific policy for monitoring residents' conditions, and expectations for monitoring were not clearly defined or followed. The resident experienced worsening respiratory symptoms, including labored breathing, wheezing, and changes in mental status, which were not adequately assessed or reported. On the night of the incident, the resident was found unresponsive with a critically low oxygen saturation and was transferred to the hospital, where they were diagnosed with pneumonia, acute hypoxic respiratory failure, and septic shock, and subsequently died. Emergency services and hospital staff noted a lack of detailed information from the facility regarding in-facility respiratory care and monitoring prior to transfer.