F0684

J

Failure to Respond to Resident’s Acute Respiratory Distress and Request for 911

College Station, Texas Survey Completed on 01-29-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s expressed wishes during an acute change in condition. The resident involved was an older female with intact cognition (BIMS 15) and significant cardiac and renal comorbidities, including diastolic CHF, hypertension, paroxysmal atrial fibrillation, aortic stenosis, and end-stage renal disease on hemodialysis. Her care plan included monitoring and prompt reporting of significant changes in pulse, respirations, and blood pressure, administration of oxygen as ordered, and reporting signs and symptoms of malignant hypertension or other changes in condition. Prior oxygen saturation readings for this resident generally ranged from 91% to 98% on room air, and she had a PRN order for 2 L/min oxygen for shortness of breath.

On the morning in question, video review showed the resident asking an LVN for oxygen, with the LVN acknowledging that the resident’s face looked flushed and obtaining vital signs, including an O2 saturation of 92% on room air. The resident repeatedly requested oxygen, became increasingly anxious, grimaced, breathed more heavily, and held her chest while stating she needed oxygen. The LVN left the room without immediately providing oxygen, and the resident’s distress continued, with difficulty talking and heavier breathing observed on video. Several minutes later, the LVN returned with oxygen, reported an O2 saturation of 97%, placed the oxygen on the resident, and then exited the room. The LVN later stated that the original oxygen tank in the room was not working, that the resident became flushed and more upset while waiting for oxygen, and that she did not call 911 or the physician, believing it was not necessary until she finished her assessment.

Subsequently, the ADON entered the room while the resident was on 2 L/min oxygen and on the phone with a family member. Video review and nursing notes reflected that the resident was crying, repeatedly stating she could not breathe, and clearly asking for 911 to be called. The ADON questioned the resident, did not complete a documented assessment at that time, did not check O2 saturation, blood pressure, oxygen tank, or tubing as observed on video, and exited the room despite the resident’s continued complaints of shortness of breath and explicit requests for 911. When the ADON re-entered, the resident again stated she could not breathe and asked for 911; the ADON removed the resident’s phone from her chest and placed it out of her reach while the family member was still on the line, and again did not perform the assessments she later claimed in interview to have done. EMS arrived shortly thereafter, found the resident’s O2 saturation at 79% while on 2 L/min oxygen, and transported her to the hospital, where she was admitted with respiratory distress and pulmonary edema/volume overload. Facility leadership and staff interviews confirmed that facility expectations were to call 911 immediately when a resident complained of shortness of breath and requested 911, and that in this case staff did not honor the resident’s repeated requests or promptly recognize and act on the acute change in condition, leading to the identified deficiency under F684 (Quality of Care).

Removal Plan

• Resident #1 was discharged/transferred to the hospital.
• Investigation completed; ADON A received disciplinary action and one-on-one re-education.
• In-service completed for licensed nurses, nurse aides, and medication aides on honoring resident wishes when requesting 911; comprehension to be verified by post-test.
• Director of Nurses in-serviced by Clinical Service Director on honoring resident wishes when requesting 911, with a post-test.
• Interviewable residents to be interviewed to ensure staff are honoring their wishes; any identified concerns to be addressed immediately.
• Non-interviewable residents to be observed to ensure no change in condition is present; document on life satisfaction survey forms; administrator to review and address concerns immediately.
• Director of Nurses/designee to continue in-servicing newly hired staff (including PRN and agency, if utilized) during orientation on honoring residents’ wishes when wanting 911 called.
• Department heads to conduct daily rounds on assigned rooms (documented on life satisfaction survey forms) to interview/observe residents to ensure staff are honoring wishes (including requests to call 911); administrator to review documentation and address concerns immediately.
• Impromptu QAPI review of the plan of removal completed with the Medical Director; Medical Director reviewed and agreed with the plan.