Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a resident experiencing a change in condition that required medical intervention. The resident, who had diagnoses including esophageal cancer, lung cancer with brain metastasis, anxiety, COPD, and dyspnea, called 911 himself after reportedly attempting to contact nursing staff for 45 minutes without success. Upon arrival, emergency responders found the resident in his bed, alert but in obvious respiratory distress, with an oxygen saturation of 88% on room air and labored respirations. The ambulance crew noted that the resident's abdomen was distended and rigid, and his respiratory effort improved only after oxygen was administered. The paramedics and police reported that no staff were present in the area for at least 10 minutes after their arrival, and the resident was loaded onto the cot before any staff appeared. Documentation in the resident's electronic medical record showed no recorded vital signs or assessments between the evening prior to the incident and the time of transfer to the hospital. The last documented vital signs were from the previous day, and there was no evidence of staff response to the resident's attempts to seek help during his respiratory distress. Interviews with staff indicated that the nurse was occupied on another unit and did not hear calls for assistance, while another resident reported hearing the affected resident yelling for help. The assigned CNA could not be reached for comment prior to the survey exit.