Failure to Notify Physician of Resident’s Ongoing Shortness of Breath
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s primary physician of a significant change in respiratory status over several days. The resident was admitted with COPD, emphysema, and hypertensive heart disease and had moderate cognitive impairment, requiring partial to moderate assistance with activities of daily living. The resident’s care plan for impaired gas exchange and ineffective airway clearance related to COPD included interventions to assess respiratory function, monitor for respiratory changes, and notify the physician as indicated. Progress notes documented that, beginning on 2/7/2026, the resident experienced shortness of breath, initially while lying flat, and then on subsequent days continued to report and exhibit shortness of breath. These respiratory symptoms were documented on 2/7, 2/8, 2/9, 2/10, and 2/11, but there was no documentation or evidence that the resident’s physician was notified of this ongoing change in condition. Facility nursing staff, including an LVN and an RN, later acknowledged that the resident’s shortness of breath had been present since 2/7/2026 and that the physician should have been notified during that period. On 2/12/2026 at 3:26 a.m., an SBAR was completed identifying a COPD exacerbation with severe shortness of breath, and an order was entered at 4:34 a.m. to transfer the resident to an acute care hospital. Emergency medical services documented that the resident reported having shortness of breath for the past five days without help and was found to have an oxygen saturation of 82% on room air when picked up from the facility. The hospital emergency department record indicated the resident presented with progressively worsening shortness of breath over six days. The facility’s own policy on change in a resident’s condition required nursing staff to notify the attending physician when there was a significant change in the resident’s physical condition or a need to transfer the resident to a hospital, which did not occur during the days when the resident’s shortness of breath was repeatedly documented.
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