Failure to Provide Rescue Breathing and Supervision After Resident Fall With Abnormal Breathing
Penalty
Summary
The deficiency involved the facility’s failure to provide appropriate emergency respiratory interventions, including rescue breaths or assisted ventilation, to a resident who was found on the floor after a fall. The resident had a history of intellectual developmental disability and severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the day of the incident, a CNA reported that the resident had been independently wheeling himself in the hallway, was provided a meal tray, and ate independently. The CNA stated she was not informed the resident was a fall risk and that the resident remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and observed nursing staff with the resident lying face down on the floor with a bleeding head wound. Multiple CNAs and licensed nurses described the resident’s condition after the fall as minimally responsive, non-responsive, or having irregular or agonal breathing. One CNA reported that the resident had been seen earlier in the hallway sitting in his wheelchair, making random sounds, not fully verbal, and attempting to stand up from the wheelchair, and that she had been informed by licensed nurses that the resident was a fall risk. However, neither she nor another CNA were instructed to monitor or supervise the resident, including when the assigned CNA left the area to use the restroom. After the fall, staff observed the resident on the floor with a bleeding forehead, non-responsive, with irregular breathing and body twitching, and oxygen was applied via a non-rebreather mask. Licensed nursing staff interviews and record review confirmed that, following the fall, the resident had a pulse but was experiencing agonal or irregular breathing, and that staff did not assess chest rise and fall to determine effective breathing and did not provide rescue breaths. One nurse stated that the only intervention provided was oxygen via a non-rebreather mask and acknowledged that chest compressions were inaccurately documented as having been performed when they were not. Another nurse stated that the resident’s oxygen saturation was not registering on the pulse oximeter, that she did not check for chest rise, and that she did not provide rescue breaths despite uncertainty about the resident’s respiratory status. The Director of Staff Development and the DON stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing at a rate of one breath every six seconds for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation or ensure air movement into the lungs. The facility’s policy indicated staff are trained to follow current AHA guidelines for recognition of cardiac arrest, initiation of resuscitation, and opening the airway.
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