Failure to Monitor and Follow Up on Resident Respiratory Change in Condition
Penalty
Summary
The facility failed to assess, monitor, and intervene appropriately when a resident experienced a change in respiratory status. The resident, who had severe cognitive impairment, sepsis, pneumonia, and a chronic nasogastric tube, was care planned as being at elevated risk for pneumonia, with interventions including administering nebulizers as ordered and observing for signs and symptoms of pneumonia. On one date, progress notes documented that the resident’s family inquired about the need for nebulizer treatments, and the resident was observed to be uncomfortable, coughing, and making a distressing facial expression, prompting an order for a chest x-ray. The x-ray showed right upper lung atelectasis versus consolidation related to pneumonia. Subsequent progress notes documented that the resident was to receive albuterol nebulizer treatments three times a day for four days with a repeat chest x-ray, and that the family reported the resident was short of breath, although staff did not find concerns upon assessment. The family later requested a nebulizer treatment, and the medication record showed the resident received albuterol nebulizers three times a day over several days. Despite the order to repeat the chest x-ray after the nebulizer course, no follow-up x-ray was completed, and there was no progress note documentation for a several-day period to show the resident’s status following the identified change in condition. When documentation resumed, notes indicated the resident had increased congestion, required airway suctioning, had a fever of 101.4 degrees, and was transferred to the hospital, where records described progressive respiratory symptoms over two weeks, shortness of breath, altered breath sounds over the prior week, and fevers occurring the previous night and a few days earlier. The family reported that the resident had respiratory symptoms for two weeks and had no treatment besides nebulizers. The DON later acknowledged that there was no documentation from the gap period to show the resident’s status and that staff should have been documenting the resident’s condition given the change, and the Administrator confirmed there was no follow-up chest x-ray in the medical record.
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