F0658

D

Failure to Intervene and Notify Physician for Resident With Respiratory Decline and Altered Consciousness

Los Angeles, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care and services that met professional standards of practice for a resident with COPD, asthma, diabetes, and influenza, who had a POLST indicating DNR status but allowing selective treatment, including IV therapies, non-invasive positive airway pressure, and hospital transfer if comfort needs could not be met. The resident’s care plan directed staff to observe for signs and symptoms of respiratory insufficiency such as anxiety, confusion, and shortness of breath and to refer to the physician as needed. Physician orders allowed oxygen at 2 L/min via nasal cannula as needed for oxygen saturation below 93% on room air.

On one day, a Change in Condition (COC) evaluation documented that the resident’s O2 saturation dropped to 88%, and oxygen was administered via non-rebreather mask, then changed to nasal cannula when stabilized. Progress notes later that evening documented another O2 desaturation to 88%, with oxygen via non-rebreather at 3 L/min improving saturation to 96%, then changed to nasal cannula with O2 saturation at 95–96%. The RN supervisor reported notifying the physician of the low O2 saturation and oxygen administration, and the physician ordered to make the resident comfortable and continue monitoring. Additional progress notes indicated that around 6:00 p.m. the resident had an episode of vomiting and continuous coughing, with O2 saturation less than 94%; the RN supervisor was notified and oxygen was administered, and the resident was monitored for decline.

Later that night, progress notes documented that the resident was unable to accept medication due to partial waking and was unresponsive to commands, but there was no documentation of any interventions provided or physician notification regarding this change in condition. A subsequent note around 11:46 p.m. stated that on initial rounds the resident was observed on a non-rebreather mask at 8 L/min with labored breathing, and attempts to obtain vital signs were unsuccessful; on reassessment at approximately 11:46 p.m., the resident was unresponsive with no palpable pulse and no chest rise, and no code was initiated due to DNR status. This note also did not document any interventions for the labored breathing or physician notification at that time. A CNA reported observing the resident with labored breathing around 11:00 p.m. and notifying an LVN, who responded that the resident was a DNR. The physician later stated he had been informed earlier of the low O2 saturation that stabilized with oxygen and had instructed staff to continue monitoring, and that he was surprised to receive a later call informing him of the resident’s death, stating the resident should have been transferred to the hospital if the condition had not improved. The DON acknowledged that the resident had another significant change in condition and should have been transferred. Facility policies and job descriptions required prompt physician notification of significant changes in condition and documentation of such changes, which were not followed in this case.