F0842

D

Failure to Assess, Obtain Orders, and Accurately Document Resident Respiratory Change in Condition

Eureka, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves a licensed nurse’s failure to complete and maintain an accurate medical record and to document a change in condition (COC) and related assessments and treatments for a resident with chronic respiratory disease. The resident had COPD and asthma and a care plan that directed licensed nurses to administer aerosol or bronchodilators as ordered, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. Facility policy and contract orientation information for the nurse required that when a change in condition was identified, the assigned licensed nurse complete an SBAR, notify the licensed independent practitioner immediately, and document the date, time, details of the event, assessment, physician notification, and any orders received.

On the day in question, CNA 1 reported that at the start of her shift at 3 p.m. the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 stated the resident’s O2 saturation fluctuated between 85–95% on room air and that she escalated these concerns to LN 1, who responded that the resident was fine. CNA 1 reported that as time passed, the resident’s breathing sounds worsened and that she notified LN 1 three or four more times that the resident was getting worse, but LN 1 continued to say the resident was fine. CNA 2 corroborated that CNA 1 was worried about the resident early in the shift, that the resident was acting differently and gurgling, and that the O2 saturation was very low, the lowest CNA 2 had ever seen. CNA 1 stated that when the O2 saturation read 35%, she asked CNA 2 to help get LN 1 to physically assess the resident, and that LN 1 did not assess the resident until nearly four hours after the initial notification.

The medical record review showed no documented assessment, COC entry, physician notification, treatment, or monitoring of treatment effectiveness related to the resident’s respiratory status between 3 p.m. and 6:30 p.m., despite an active order requiring staff to add a progress note each shift regarding lung sounds. The only documented COC by LN 1 was a progress note time-stamped 7:43 p.m., which stated that around 6:40 p.m. CNA 1 notified LN 1 that the resident was breathing rapidly, that the resident’s O2 saturation was 93%, and that LN 1 asked if the resident wanted to go to the hospital and the resident declined. LN 2’s note documented that upon arriving on shift at 6:53 p.m., CNA 1 reported the resident had shortness of breath and an O2 saturation of 63% on room air, that the monitor showed 72% on room air, that LN 2 instructed LN 1 to call 911, and that the resident was unresponsive with labored, rapid breathing and a very faint pulse, with CPR initiated by staff and then taken over by EMS.

Further record review and interviews revealed discrepancies and omissions in documentation of a breathing treatment. The ER provider note indicated the resident’s last known normal was 6:30 p.m. and listed an albuterol nebulizer order as a PRN medication the resident was not taking. A late-entry progress note by LN 1, dated two days later at 3:34 p.m., stated that at approximately 6:45 p.m. on the day of the event, LN 1 administered a breathing treatment and that while LN 1 was on the phone, the resident started to code and the non-emergent transfer call was switched to 911. There was no documentation in that note of what specific medication was given or that it was administered on the correct date. The MAR showed no evidence that albuterol nebulization solution was administered on any day that month, and the physician confirmed she had not been notified of the resident’s shortness of breath that day and had not been called for a respiratory treatment order prior to the code. A physician’s order for a one-time albuterol nebulizer dose was created later that evening and then discontinued with the reason that the resident expired in the emergency department. The facility’s medical records department confirmed there were no other notes by LN 1 that day beyond the 7:43 p.m. entry, and the DON stated nurses were expected to document COCs, assessments, interventions, physician notifications, and resident responses, and to obtain and document orders for oxygen and breathing treatments when O2 saturation was critically low.