F0684

G

Failure to Provide Timely Respiratory Assessment, Physician Notification, and Lab Follow-Through After Change in Condition

Stockton, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate respiratory care, timely clinical assessment, and appropriate physician notification for a resident with complex medical conditions, including sepsis, facial cellulitis, type 2 diabetes, hypertension, morbid obesity, sleep apnea, and blindness. The resident was admitted from the hospital with discharge instructions that included oxygen at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification, and weekly CBC and Chem 7 labs after SNF admission. The facility signed that these hospital discharge orders were noted and would be carried out, but the weekly CBC order was never transcribed into the facility’s physician orders, and there was no evidence that CBC labs were ever drawn. The DON confirmed that the CBC order was not transcribed or completed, despite the resident being on IV antibiotics for infection.

On the morning of the incident, the resident was in bed with CPAP and oxygen at 2 L/min via nasal cannula. Around change of shift, a CNA informed LVN 1 that the resident was complaining of shortness of breath and had an oxygen saturation of 88%. LVN 1 assessed the resident, confirmed shortness of breath and low oxygen saturation, administered two puffs of albuterol as ordered, and increased the resident’s oxygen from 2 L/min to 3 L/min and then to 4 L/min via nasal cannula, using her own nursing judgment. LVN 1 documented that the oxygen saturation improved to 94–95% by 8:15 a.m. and stated she remained in the room monitoring the resident until that time. LVN 1 acknowledged that this was a change in condition and that she did not notify the physician, explaining that she was passing medications and did not get the chance to call. The SBAR and progress notes showed that the physician was not notified of the change in condition until after the resident was found unresponsive.

The facility’s DON stated that it was not within an LVN’s scope of practice to perform a full clinical assessment for a change in condition or to adjust oxygen flow rates under the updated respiratory care regulations. The DON confirmed that LVN 1 did not escalate the resident’s care to an RN for a full assessment and that LVN 1 should not have titrated the oxygen without a physician’s order. The DON also confirmed that there was no oxygen therapy care plan developed for the resident, despite the resident being on oxygen therapy. Later that morning, at approximately 10:10 a.m., the NP found the resident in bed unresponsive, with no pulse and no respirations, and the CPAP still in place even though the order specified CPAP off at 7 a.m. A code was called, CPR was initiated, and 911 was contacted, but paramedics pronounced the resident deceased at 10:26 a.m. The NP and Medical Director both stated that staff should not have titrated oxygen without an order and that they were not notified of the resident’s earlier change in condition involving shortness of breath and low oxygen saturation.

The facility’s written policy on change in resident condition required prompt notification of the attending physician when there is a significant change in the resident’s physical condition, including specific instructions to notify the physician of changes in condition. The facility’s in-service education and regulatory guidance from the Respiratory Care Board and the Board of Vocational Nursing and Psychiatric Technicians specified that LVNs may not initiate or adjust oxygen liter flow or concentration and must work under the supervision of an RCP, RN, or physician. Despite these policies and regulations, LVN 1 independently adjusted the resident’s oxygen flow, did not notify an RN or physician of the change in condition, and the facility did not ensure transcription and implementation of the hospital’s weekly CBC orders. These combined failures resulted in the physician not being aware of the resident’s change in condition, a delay in adequate assessment and potential identification of the need for a higher level of care, and delay in adequate care and treatment, and the resident died within two hours of the documented change in condition.