F0580

J

Failure to Notify Physician and Family During Resident’s Acute Respiratory Decline

Syracuse, New York Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative when there was a significant change in the resident’s condition. Facility policy required the nurse supervisor or charge nurse to notify the attending or on-call physician for any significant change in a resident’s physical, emotional, or mental condition, or when a transfer to a hospital was needed, and to inform the resident’s family or designated representative of such changes. Resident #11 had diagnoses including respiratory failure, obstructive sleep apnea, and hypertension, and had an order for 4 liters of oxygen via nasal cannula every shift. The resident was documented as cognitively intact and able to make themselves understood.

On the night of the incident, progress notes documented that around 1:00 AM the resident was resting comfortably with no signs of acute distress and remained stable and responsive through the night until approximately 5:00 AM. At that time, the resident was found with labored respirations and minimally responsive to verbal stimuli, with an oxygen saturation of 40% on 4 liters via nasal cannula. The supervisor was notified and changed the nasal cannula to an oxygen mask. Multiple pulse oximeters were used, showing readings of 42%, 43%, and 26%, and the resident’s labored breathing continued. Oxygen therapy was escalated to 10 liters via non-rebreather mask using a portable oxygen tank without a physician order. Despite these significant changes in respiratory status and very low oxygen saturation levels, there was no documented evidence that the medical provider was notified at the time of the change.

Emergency Medical Services were not called until approximately 6:00 AM, after the resident’s condition had further deteriorated. Upon EMS arrival, the resident became unresponsive and was transported to the hospital, where emergency department documentation described the resident as responding only to pain, in respiratory distress with agonal breathing, and on high-flow oxygen. The resident was later pronounced deceased due to respiratory arrest. Interviews with staff revealed that the nursing supervisor on duty acknowledged not calling the nurse practitioner, delaying calling 911 while attempting to manage the resident’s oxygen levels, and forgetting to call the family. Other nursing staff described a protocol in which significant changes in condition, especially oxygen saturations in the 40% range or respiratory distress, should prompt immediate notification of a supervisor, provider, and/or 911. The resident’s health care proxy stated they did not receive any calls from the facility about the change in condition or the transfer to the hospital. The Director of Nursing and Medical Director both stated that the provider should have been called and that failure to call the provider or 911 immediately constituted a delay in treatment.

The surveyors determined that the facility failed to follow its own Change in Resident Condition policy by not immediately consulting the physician when Resident #11 experienced a significant change in respiratory status, and by not notifying the resident’s family or representative. This failure occurred despite multiple extremely low oxygen saturation readings, labored breathing, and decreased responsiveness, and despite staff recognition in interviews that such findings represented an urgent or emergent situation requiring provider notification and/or calling 911. The lack of timely physician consultation and family notification, combined with delayed activation of EMS, formed the basis of the cited deficiency and was determined to have resulted in Immediate Jeopardy to the resident and placed other residents with potential significant respiratory changes at risk for serious harm, serious impairment, serious injury, or death.

Removal Plan

• All residents on oxygen had a pulse oximetry reading completed and any results deviating from the resident's baseline had a registered nurse assessment and physician notification via telephone.
• Education for licensed nursing staff was implemented on the Change in Resident Condition Policy requiring documented physician notification via telephone for all significant changes in resident condition.
• All oncoming licensed nursing staff would be educated on the Change in Condition Policy.
• Licensed nursing staff were educated on the Change in Condition Policy.