F0684

D

Failure to Assess, Obtain Orders, and Appropriately Respond to Resident Respiratory Decline

Eureka, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide nursing care that met professional standards for a resident with COPD and asthma who experienced a significant change in respiratory status. The resident’s care plan directed licensed nurses to administer ordered aerosol or bronchodilators, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. The facility’s orientation materials and Change in Condition policy required licensed nurses to promptly assess changes in condition, complete an S-BAR, notify the practitioner immediately, and document the assessment, interventions, and physician notification. The resident also had orders for CPR in the event of cardiac or respiratory arrest and for shift-by-shift lung sound documentation, which were later discontinued after the resident’s death.

On the day of the incident, CNA 1 reported that at the start of her shift the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 measured the resident’s O2 saturation, which fluctuated between 85–95% on room air, and repeatedly notified LN 1, who responded that the resident was fine and did not initially assess him. CNA 1 stated she reported the resident’s worsening condition three or four more times as his breathing sounds deteriorated, but LN 1 continued to say he was fine. When the resident’s O2 saturation later dropped to 35%, CNA 1 asked CNA 2 to help get LN 1 to assess the resident because LN 1 had not been listening to her concerns. CNA 2 corroborated that CNA 1 had been worried from the beginning of the shift, that the resident was gurgling with very low O2 saturation, and that she notified LN 1 of these concerns.

There was no documented assessment or change-of-condition note in the medical record for the period between approximately 3 p.m. and 6:30 p.m., and no documentation of physician notification, treatment provided, or monitoring of treatment effectiveness during that time. LN 1 later documented in a progress note that around 6:40 p.m. she was notified by CNA 1 that the resident was breathing rapidly, that his O2 saturation was 93%, and that she asked if he wanted to go to the hospital and he said no; CNA 1 later stated she did not hear LN 1 ask the resident about going to the hospital. LN 1 also documented, in a late entry, that she administered a breathing treatment at approximately 6:45 p.m. while on the phone, and that the resident started to code while she was on the call. However, there was no documentation of what medication was given, and the Medication Administration Record showed no albuterol nebulizer doses given that month. The DON confirmed the resident had medicated breathing treatments in the cart but no active order, as the prior order had expired.

Around 7 p.m., CNA 1 reported to LN 2 that the resident had shortness of breath and an O2 saturation of 63% on room air; LN 2 recorded an O2 saturation of 72% on the monitor, found the resident unresponsive with labored, rapid breathing and a very faint pulse, and instructed LN 1 to call 911. LN 2 stated she specifically told LN 1 to call 911, but LN 1 instead called a non-emergent ambulance, and when questioned why she did so in an emergency, LN 1 did not respond. LN 2 documented that chest compressions were initiated, oxygen was applied via mask, and EMS arrived and took over CPR. The ER provider note indicated EMS reported the resident was found down and apneic by facility staff about 30 minutes before arrival, with last known normal at 6:30 p.m. The resident’s physician stated she had not been notified by LN 1 earlier in the day about the resident’s shortness of breath, had not been asked for a respiratory treatment order, and only received a call after the resident had coded and been sent to the hospital. The facility’s policies required assessment, timely physician notification, documentation of change in condition, and calling 911 in a cardiopulmonary emergency, all of which were not followed by LN 1 in this case.