Failure to Assess Resident Reporting Shortness of Breath
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including a history of stroke, heart failure, and severe cognitive impairment, reported difficulty breathing to staff. The resident's care plan specifically required monitoring and documentation of changes in breathing patterns and prompt reporting of abnormalities to a physician. On the evening in question, the resident verbally expressed to a Restorative Aide that she could not breathe. The aide notified an LVN, who, along with other staff, entered the room. The LVN questioned the resident about her symptoms and medication but did not perform an assessment or check vital signs, including oxygen saturation, as required by the care plan and professional standards of practice. The LVN then instructed staff to leave the room, and no immediate clinical assessment was performed at that time. Subsequently, a family member, observing the situation remotely, called the facility to express concern about the resident's breathing. Another nurse responded to the call, assessed the resident, and documented normal oxygen saturation levels and no signs of distress. The hospice nurse was also called and confirmed the resident was stable upon her arrival. However, the initial failure to assess the resident when she first reported difficulty breathing was corroborated by interviews with staff, the family member, and review of video footage. The Director of Nursing and the Administrator both acknowledged that the LVN did not follow protocol by failing to assess the resident's respiratory status when the concern was first raised. The facility's policy required staff to assess, evaluate, and respond to residents' needs, including performing necessary clinical assessments when a resident reports symptoms such as shortness of breath. The deficiency was identified based on the lack of immediate assessment and documentation when the resident expressed respiratory distress, despite clear care plan interventions and facility policy. This lapse was confirmed through interviews, record reviews, and video evidence.