Failure to Notify Physician and Family After Resident Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and the resident’s family of a significant change in condition following a choking event. Facility policy titled “Guidelines for Notifying Physicians of Clinical Problems,” revised February 2014, states that the charge nurse or supervisor should contact the attending physician any time a clinical situation requires immediate discussion and management, and specifically identifies tachypnea and dyspnea with a pulse oximetry below 90% as requiring immediate notification. Resident 1, who was documented on a recent Quarterly MDS as severely cognitively impaired, experienced a distressful choking episode while eating breakfast in the room. A CNA had the resident sitting upright and repositioned the resident more upright prior to notifying the licensed nurse. The licensed nurse responded, suctioned small amounts of breakfast food from the resident’s mouth, and documented an initial oxygen saturation of 86%, after which oxygen at 2 L was applied, improving saturation to above 90% with improved color and clear lungs without evidence of aspiration at that time. Record review of the resident’s electronic medical record showed no documentation that the physician was notified of the choking incident or the low oxygen saturation, and there was also no documentation of family notification. In interview, the assigned RN (Staff C) confirmed she was informed the resident was choking, went to the room, performed suctioning, and applied oxygen after noting an SpO2 of 86%, but acknowledged that no notification was made to the resident’s physician or family and stated she did not recall when notifications should be made. The DON/RN (Staff B) stated that any change in condition required immediate provider notification via phone call and that staff were trained during orientation to report changes of condition to providers. Staff B further stated that, based on the documentation of the breakfast choking event, it would be considered a change in condition and the physician should have been notified. The survey report states that this failure placed residents at risk of unmet care needs, lack of physician oversight and interventions, and diminished quality of life.
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