F0684

J

Failure to Act on Respiratory Changes, STAT Orders, and Antibiotic Therapy

Winter Haven, Florida Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves failures to report abnormal diagnostic results, complete ordered STAT labs, assess and document changes in condition, and timely administer ordered antibiotics for two residents with respiratory symptoms and complex medical histories. For one resident with dementia, hypertension, and anxiety, a CNA observed during an overnight shift that the resident was "not herself" and later found her sitting on the side of the bed gasping for air. The CNA reported this to an LPN, who attributed it to hiccups, attempted to obtain vital signs but could not get a pulse or O2 saturation due to cold hands, and then only "kept an eye" on the resident. There was no documented assessment, change in condition note, or provider notification related to this breathing concern. Later that day, another LPN documented that the resident had shortness of breath, slightly labored breathing, and an O2 saturation of 73% on room air, and obtained orders for O2 at 2 L, STAT CBC, STAT CMP, STAT chest x‑ray, nebulizer treatments, and UA/CS.

For this same resident, the ARNP ordered STAT labs and a STAT chest x‑ray for shortness of breath, but the laboratory company reported there was no requisition or ticket for STAT labs and confirmed that no labs were drawn that day. The facility’s process required nurses to enter STAT orders into the lab website and mark them as STAT to trigger timely collection, which did not occur. A chest x‑ray was completed and reported to the facility, showing cardiomegaly, suggestion of mild pulmonary venous hypertension, and interval worsening of pulmonary congestion. There was no documentation that any provider was notified of these abnormal x‑ray results. That night, the CNA again found the resident unresponsive but breathing, without oxygen in place and with the concentrator unplugged. The LPN on duty documented that on arrival the resident was pale with gasping breaths, BP 96/60, pulse 58, RR 4–6, and O2 saturation 73% on 2 L O2, followed by cessation of respirations and loss of pulse, initiation of CPR, and transfer to the hospital. The PCP, partner physician, and ARNP all stated they had not been notified of the chest x‑ray results and would have given treatment orders if they had been informed.

A second resident with dementia, aphasia, hemiplegia, and multiple comorbidities developed a cold, fever, and increasing respiratory symptoms over several days. A CNA reported that the resident was on oxygen and febrile over a weekend and appeared worse by Monday morning, when the resident’s representative found him lethargic, clammy, mottled, and gasping for air and requested immediate transfer to the hospital. On the prior Saturday, an LPN contacted the PCP when the resident’s temperature was 102°F, O2 saturation 89%, and lung sounds had crackles; the PCP ordered O2, nebulizer treatments, Ceftriaxone IM daily for three days, STAT chest x‑ray, STAT CMP, and STAT CBC. The weekend supervisor LPN entered orders for chest x‑ray, labs, Ceftriaxone, nebulizers, and O2, but the CBC and CMP were entered as routine labs for a later date rather than STAT, and there were no flu or COVID swab orders that day. The lab company later confirmed that STAT labs require a specific STAT ticket entry, and the DON confirmed that routine labs are not drawn on Sunday, delaying lab completion until Monday.

For this second resident, the MAR showed that Ceftriaxone was not administered on the day it was ordered and was first entered to start the following day, when it was documented as refused, with no documentation that the provider or resident representative was notified of the refusal. The pharmacy confirmed that three doses of Ceftriaxone were delivered early the next morning and that no doses were pulled from the electronic medication dispensing machine on the day of the order or the following day. An LPN working the Sunday night shift stated she noticed the antibiotic had not been given and administered a dose between 1:00–2:00 a.m. Monday but did not document it. Progress notes documented fever, shortness of breath with labored breathing, abnormal vital signs, and new irregular pulse, with orders for additional labs, viral testing, repeat chest x‑ray, and PRN medications. Labs drawn Monday morning showed critically high sodium, elevated BUN and creatinine, hyperglycemia, and positive influenza A. The PCP later stated he expected labs to be completed as ordered and to be notified of results, and that if he had seen the critically high sodium on Saturday he would have ordered fluids. The surveyors determined that these failures resulted in a worsened condition and the likelihood for serious injury and/or death and cited Immediate Jeopardy, later reduced after verification of removal of Immediate Jeopardy.