Failure to Notify Provider and Responsible Party After Resident's Hypoxia Episode
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident's responsible party (RP) after a resident experienced an episode of hypoxia. The resident, who had diagnoses including dementia, major depressive disorder, and Parkinson's disease, was admitted with severely impaired cognition and required substantial to total assistance with activities of daily living. The resident had an existing physician's order for oxygen via nasal cannula as needed for hypoxia. On the date of the incident, nursing staff assessed the resident for hypoxia, noting an oxygen saturation of 83-85% on room air and a respiratory rate of 30 per minute. Oxygen was applied and titrated to 1 L/min, resulting in an improved oxygen saturation of 93%. However, the nursing documentation did not indicate that the medical provider or the resident's RP were notified of this change in condition. Interviews with the registered nurse and the Director of Long-Term Care confirmed that neither the provider nor the RP were notified, and there was no documentation of such notification in the resident's records. Both staff members acknowledged that facility policy requires notification of the provider and RP for any change in condition, and that this was not followed in this instance. The facility's policy specifically states that the provider and responsible party must be notified of significant changes in a resident's status, and documentation of the notification must be maintained.