F0684

D

Failure to Initiate Emergency Response for Resident in Respiratory Distress

Fairfield, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate emergency treatment and care according to physician orders, resident preferences, and established policies when a resident experienced acute respiratory distress and altered mental status. The resident had been re-admitted with diagnoses including pneumonia and acute and chronic respiratory failure with hypoxia and had a POLST indicating full code status. An MDS assessment documented intact cognition at baseline. On the date of the incident, an SBAR noted hypoxia, altered level of consciousness, and shortness of breath.

According to the nurse’s notes, at approximately 9 p.m. a licensed nurse entered the resident’s room to administer bedtime medications and found the resident awake, able to take medications, but repeatedly saying the same sentence. The nurse documented that when asked if he was okay, the resident opened his eyes and then closed them again. The resident’s O2 saturation was 84% on 3 L O2 via nasal cannula; the nurse increased the oxygen to 4 L, but the O2 saturation remained low at 82–83%. The nurse contacted the on-call physician at 9:30 p.m., obtained an order to send the resident to the emergency room for hypoxia, and arranged a non-emergency transport that arrived at 9:45 p.m., with transfer out at 10 p.m. There was no documentation that staff changed the nasal cannula to a non-rebreather mask.

In interviews, the licensed nurse stated she noted the resident’s difficulty breathing, continuous oxygen use, low O2 saturation, and behavior not consistent with baseline, and that she called the on-call physician, who ordered transfer to the ER. The DON stated that respiratory distress with O2 saturation below 88% and decreased level of consciousness requires activation of the emergency response system by calling 911, and confirmed that the resident’s condition warranted a 911 transfer. The nurse practitioner, after reviewing the case and ER records, stated the resident should have been transferred via 911 due to hypoxia, altered responsiveness, and continued desaturation despite oxygen, and noted that ER records showed a GCS of 7 on arrival and subsequent intubation for acute respiratory failure. The facility’s policies on Emergency Procedures and Change of Condition require immediate medical care and initiation of emergency procedures, including calling 911 and providing first aid until emergency personnel arrive, and the California Nursing Practice Act requires initiation of emergency procedures based on observed abnormalities. The failure to call 911 and initiate an emergency response in accordance with these standards constituted the deficiency.