Failure to Notify Physician of Resident’s Significant Change in Respiratory Status
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one of three sampled residents. The resident was admitted with diagnoses including diabetes mellitus, moderate persistent asthma, and a history of venous thrombosis and embolism, and had intact cognitive function. On the evening in question, the resident experienced shortness of breath while on BiPAP at 7 p.m. An LVN reported that an RN came to the bedside, adjusted the BiPAP settings, and obtained vital signs, including an oxygen saturation of 97%. Later that evening at 10 p.m., the resident again reported difficulty breathing, muscle tightening, and not getting enough air, and the RN was again called to the bedside, where the resident received a breathing treatment. During subsequent interviews and record reviews, the RN acknowledged that he failed to initiate and implement a Change of Condition (COC) for the resident’s shortness of breath and did not report the resident’s symptoms to the medical doctor. The DON confirmed that staff failed to initiate a COC despite the resident’s complaints of not getting enough air and muscle tightening, and stated it was the RN’s responsibility to complete a COC and notify the physician. Review of the facility’s policy, “Change in Condition: Notification of,” indicated the facility must immediately consult with the resident’s physician or NP when there is a significant change in the resident’s physical condition and ensure all pertinent information is provided. This failure to follow policy and notify the physician constituted the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.