Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented