F0684

J

Failure to Follow Respiratory Orders and Monitor Resident in Respiratory Distress

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory treatment and care according to physician orders, professional standards of practice, and the resident’s comprehensive care plan for a resident with significant respiratory diagnoses. The resident had respiratory failure, obstructive sleep apnea, and hypertension, and the care plan identified risk for compromised respiratory status with interventions including monitoring respiratory status, breath sounds, vital signs, and providing oxygen per physician order. A physician order dated 11/18/2024 required four liters of oxygen via nasal cannula every day, every shift. On 11/25/2025, the resident complained of intermittent shortness of breath, and a respiratory therapist assessed the resident, documented oxygen saturation of 92% on three liters of oxygen, and switched the resident to an oxygen concentrator at three liters without checking the current physician order for four liters.

There was no documented evidence that a registered nurse assessed the resident when they were experiencing shortness of breath on 11/25/2025, nor that the resident’s respiratory status was monitored as outlined in the care plan. The resident’s health care proxy reported that on the same day, family members found the oxygen concentrator not working, notified staff, and another family member placed the resident on a portable oxygen tank; when they left at 5:00 PM, no staff had come to address the oxygen issue. These events indicate that the resident’s respiratory complaints and equipment concerns were not appropriately addressed, and physician orders for oxygen therapy were not followed.

On 11/26/2025, between approximately 4:30 AM and 5:00 AM, a CNA notified an LPN that the resident was not breathing right. The LPN found the resident minimally responsive with labored breathing and an oxygen saturation of 40% on four liters via nasal cannula, and contacted an RN, who instructed the LPN to place the resident on a face mask but did not remain in the room. The LPN later rechecked the oxygen saturation, which remained in the 40s with increased labored breathing, and escalated the portable oxygen to ten liters via non-rebreather mask without a provider order. There was no documented RN assessment of the resident’s declining condition and no documentation that a physician was notified. Emergency Medical Services records show 911 was called at 6:04 AM, and upon arrival the resident was unresponsive with agonal respirations and no staff present on the unit, requiring EMS to call the fire department for assistance. These actions and omissions demonstrate failure to monitor and respond to a significant change in condition, failure to follow physician orders, and failure to provide supervision while awaiting EMS, resulting in Immediate Jeopardy and substandard quality of care for the resident.

Removal Plan

• Complete a pulse oximetry reading for all residents on oxygen and ensure any results deviating from the resident's baseline receive a registered nurse assessment and physician notification via telephone.
• Ensure any resident demonstrating respiratory distress is not left unattended while awaiting Emergency Medical Services.
• Review all resident accident and incident reports for the last 30 days.
• Review any significant change in status and abnormal laboratory results requiring action to ensure they were addressed and determine whether treatment needed to be significantly altered or the resident needed to be transferred.
• Re-educate Registered Nurse #8 on assessments and supervision.
• Educate licensed nursing staff on the Change in Condition Policy for significant change in respiratory status.
• Educate licensed nursing staff on communication with the registered nurse and proper assessment of respiratory complaints.
• Educate certified nursing assistants on communicating respiratory changes in condition and other changes in condition to licensed nursing staff.
• Educate licensed nursing staff on following physician orders and performing within scope of practice.
• Educate licensed nursing staff on obtaining vital signs with a change in condition.