Failure to Provide Immediate Assessment and Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to meet professional standards of care for a resident experiencing a change of condition. The respiratory therapist (RT) responded to an alarming pulse oximeter for a resident with severe cognitive impairment, who was found to be lethargic, unresponsive, and jaundiced. The RT attempted to troubleshoot the pulse oximeter, changed the sensor, and suctioned the resident without first checking the resident's pulse or lung sounds. Despite the resident's continued unresponsiveness and abnormal appearance, the RT did not immediately call for assistance, instead spending approximately five to eight minutes performing interventions before activating the emergency response. During this period, the RT did not document any of the actions or interventions provided to the resident, as required by facility policy and professional standards. The RT only checked the resident's pulse after other interventions failed to yield a response, at which point no pulse was detected and emergency assistance was finally summoned. The delay in calling for help and the lack of documentation were confirmed through interviews with the RT, the Director of Nursing (DON), and the RT Supervisor, all of whom stated that immediate assessment and rapid response are expected in such situations. Facility policy and professional standards, as well as statements from the DON and RT Supervisor, indicate that licensed staff are required to promptly assess residents for consciousness, breathing, and pulse, and to call for help within less than a minute if a resident is unresponsive or in distress. The RT's actions did not align with these expectations, and the absence of documentation further failed to meet the facility's requirements for recording care provided during a change of condition.