F0684

D

Failure to Reassess Resident After Respiratory Decline and Change in Condition

Minneapolis, Minnesota Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reassess a resident after a documented change in condition. The resident had a POLST specifying DNR/DNI status with a focus on comfort care, including use of oxygen and medications, and authorization for oral and IV/IM antibiotics. Prior assessments showed the resident had normal cognition, no behaviors, minimal depression, and was ambulatory with assistance for ADLs. On the evening in question, the resident developed a cough, and an RN documented that initial vital signs showed normal temperature, BP 100/63, RR 20, HR 94, but oxygen saturation at 89–90% on room air. By the end of that shift, the resident’s oxygen saturation had dropped further to 85–90% on room air, prompting initiation of 2 LPM oxygen and notification of the on‑call NP, who ordered a chest X‑ray and influenza testing.

During the subsequent night shift, the LPN reported that the resident slept and was monitored every two hours for incontinence care and repositioning, and that oxygen saturation remained above 90% on oxygen. The portable X‑ray company did not respond despite four calls, and no X‑ray was obtained. The night shift nurse documented that the resident slept all night and did not document any reassessment indicating a significant change in condition or any additional vital signs beyond the initial assessment. The facility’s administrator stated that night shift protocol was to check and turn residents every two hours and that staff documented by exception, with the expectation that staff would notify the provider and family if the resident’s condition worsened.

Later that morning, the resident received scheduled morning medications, and a progress note documented transfer to the hospital due to increased chest congestion and oxygen saturation less than 81% on 4 LPM, with the X‑ray still not completed. A late entry note recorded that the resident had cough and shortness of breath, oxygen saturation less than 80% on 4 LPM, BP 71/45, HR 108, and that 911 was called. A family member, who was the resident’s POA, reported that upon arrival that morning the resident appeared febrile, was struggling to breathe, was delusional, and did not recognize her, and that a nursing assistant had given him a bed bath and made him comfortable before the head nurse assessed him and called 911. Interviews with nursing staff and the medical director showed they understood the POLST as directing comfort care at the facility, but there was no facility policy defining comfort care, and the regional DCS could not locate such a policy. The deficiency centers on the lack of reassessment and documentation of the resident’s changing condition between the initial decline in oxygen saturation and the later, more severe deterioration that led to hospital transfer.