F0842

D

Failure to Document RN Assessment and Vital Signs During Acute Respiratory Event

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, and professionally acceptable medical records for a resident who experienced an acute change in respiratory and mental status. The resident had diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, and hypertension, and was care planned for risk of compromised respiratory status with interventions such as monitoring respiratory status, vital signs, and providing oxygen per physician order. Facility policies on Change in Resident Condition and Resident Hospital Transfer required the RN to complete and document an assessment, use an SBAR tool, and write a nursing progress note including all steps taken, the time of transfer, transport details, and report to the emergency department.

On the night in question, an LPN documented that around 1:00 AM the resident was resting comfortably and remained stable and responsive through the night until approximately 5:00 AM, when the resident was found with labored respirations and minimally responsive to verbal stimuli. The LPN documented that the resident’s oxygen saturation was 40% on 4L nasal cannula, that the RN supervisor was immediately notified and came to the bedside, changed the nasal cannula to an oxygen mask, and that oxygen saturation levels were rechecked with three separate oximeters, yielding readings of 42%, 43%, and 26% with increased labored breathing. The LPN further documented that the RN supervisor was again updated with a recommendation to send the resident to the emergency department, oxygen therapy was escalated to 10L via non-rebreather mask, and that upon EMS arrival the resident became unresponsive and was transported to the hospital.

Despite these events, there was no documentation in the medical record of the resident’s vital signs (heart rate, blood pressure, respiratory rate, and temperature) on that date, no documented assessment by the RN supervisor when the resident had respiratory and mental status changes, and no documented evidence of the resident’s response to the oxygen treatment provided. The nursing progress note entry for the RN supervisor at 5:57 AM was blank, and another RN later documented only that they received report from the LPN, that the resident’s oxygen saturation was in the low 40s, that the resident was unresponsive and vital signs were unable to be taken, that the RN supervisor had assessed the resident per the LPN, and that the resident was sent to the hospital and the NP was notified. In interviews, the LPN stated they had taken and written vital signs on a “cheat sheet,” and the RN supervisor stated they forgot to write a note; the DON stated they would expect RNs to write assessment notes and that the RN supervisor attempted but did not save a note in the computer system. These omissions resulted in an incomplete and non-compliant medical record for this resident’s acute change in condition and transfer.