F0684

G

Failure to Provide Suctioning and Oxygen During Resident Respiratory Distress

Seminole, Florida Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate respiratory treatment and airway management to a resident with known risk for thick secretions following esophageal radiation therapy. The resident had diagnoses including malignant neoplasm of the esophagus, gastrostomy status, adult failure to thrive, Alzheimer’s disease, and dysphagia, and was NPO with a PEG tube and a DNR order. The resident’s representative reported having multiple prior discussions with nursing staff about expected post-radiation side effects, specifically thick secretions that might require coughing or suctioning to clear the airway. On the evening in question, the representative was informed by nursing that the resident’s bolus tube feedings could not be administered because the resident was coughing and choking, and that the physician had ordered IV fluids, chest x-ray, abdominal x-ray, labs, and respiratory medications. The representative reiterated concerns about thick secretions and asked if suctioning was available; the nurse stated suctioning was available but had not been needed because the resident had been able to clear secretions.

Progress notes show that earlier that evening the resident was documented as having increased mucus production, phlegm, and coughing, with PEG tube feeding held and STAT diagnostics and respiratory medications ordered. Later that night, the on-call practitioner instructed staff not to send the resident to the hospital, but to administer IV fluids and await lab and diagnostic results, and the resident representative agreed with this plan, with staff documenting that increased mucus was a common side effect of radiation and that the resident was being frequently monitored with the head of bed elevated. An IV of normal saline at 100 cc/hr was started around midnight, and documentation indicated the resident was stable, responsive, and alert at the time of IV placement. However, there is no documentation that suctioning or oxygen were initiated at any point despite ongoing concerns about increased mucus and cough.

Around shortly before 1:00 a.m., staff accounts describe a significant change in the resident’s condition. A CNA reported that when she went to the room at the RN’s request, the resident was lying in bed unresponsive, breathing with sounds suggesting something stuck in his throat, and then making a gurgling sound, with foam coming from his mouth; she stated she did not see the RN or anyone else suction the resident or apply oxygen. Another CNA reported that when she entered the room, the resident had oxygen tubing on but it was not connected to an oxygen source, and that the RN never got oxygen hooked up while the resident was still breathing. The assigned RN stated he noted the resident with shortness of breath, heard crackling in the lungs but did not auscultate, obtained vital signs showing elevated blood pressure and very low oxygen saturation, administered a nebulizer treatment, attempted unsuccessfully to reach the physician, then left the room to call 911 and get oxygen, asking a CNA to watch the resident. He acknowledged that there was no oxygen or suction in the room, that he did not obtain the code cart containing oxygen and suction because the resident was DNR, and that he was unable to get oxygen on the resident before the resident took his last breaths. The respiratory therapist stated he had not been called, that staff were supposed to notify him when respiratory therapy might be needed, and that a resident with gurgling or suspected obstruction should have been suctioned and placed on oxygen, even if on hospice. The DON stated the RN’s documentation timeline did not align, that she would have expected the RN to stay with the resident, obtain the crash cart, suction the resident, and apply oxygen per the facility’s respiratory protocol, which directs staff in respiratory distress to check the airway, obtain the crash cart, place a non-rebreather mask with oxygen, suction as needed, call the physician, and call 911 if unable to stabilize the resident.