Failure to Provide and Document Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident with multiple respiratory diagnoses, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and had significantly impaired cognition. Despite physician orders for scheduled respiratory medications—Acetylcysteine, Budenoside, and Ipratropium-Albuterol—there were numerous missed and undocumented administrations over several months, as evidenced by gaps in the Medication Administration Record (MAR). These medications were specifically ordered to manage the resident's COPD, chest congestion, and shortness of breath, but the resident did not consistently receive them as prescribed. In addition to missed medications, the facility did not adequately monitor or assess the resident for respiratory distress or changes in condition, even after new symptoms and abnormal findings were identified. When a nurse practitioner noted cough, congestion, abnormal lung sounds, and respiratory distress with low oxygen saturation, and when abnormal laboratory and chest x-ray results were received indicating possible infection, there was no documented assessment or monitoring of the resident's respiratory status. The care plan was not revised to address the new or worsening symptoms, and there was no evidence of nursing interventions being initiated in response to these changes. Furthermore, the facility failed to ensure timely and effective communication of critical lab and diagnostic results to the resident's physician. Although results were faxed and texted, there was no confirmation that the physician or nurse practitioner received or reviewed the information. Nurses did not follow up with phone calls or verify receipt, and there was no documentation of provider notification or discussion of the abnormal findings. This lack of communication delayed necessary medical evaluation and treatment. Ultimately, the resident was found unresponsive and pulseless, and despite CPR, was pronounced dead. The facility's policies required prompt assessment, monitoring, and provider notification for changes in condition, but these procedures were not followed.