Failure to Timely Notify Physician of Critically Low Oxygen Saturation
Penalty
Summary
The facility failed to notify the attending physician in a timely manner when a resident experienced a critically low oxygen saturation level of 35%. The resident, who had a history of chronic obstructive pulmonary disease (COPD), anxiety disorder, alcohol use disorder, and sepsis, was admitted with orders for continuous oxygen via nasal cannula. On the night in question, the resident was found without his nasal cannula and with severely low oxygen saturation. Although oxygen was reapplied and the resident's saturation improved somewhat, there was a significant delay in notifying the physician. Multiple staff interviews and record reviews revealed that the licensed nurse on duty did not contact the physician immediately after the resident's oxygen saturation dropped to 35%. The physician was not informed of the critical event until several hours later, around 11 a.m., despite facility policy requiring prompt notification of significant changes in a resident's condition. The Director of Nursing confirmed that the resident should have been transferred to the hospital at the time of the initial event and that the lack of close monitoring and delayed physician notification could have affected the resident's treatment. As a result of the delayed notification and intervention, the resident experienced prolonged hypoxemia and discomfort, ultimately requiring emergency transfer to the hospital. Upon arrival, the resident was intubated for respiratory failure and severe hypoxemia but subsequently expired. Hospital records indicated the resident was admitted with acute hypercapnic hypoxic respiratory failure, likely secondary to pneumonia, and ultimately suffered cardiac arrest.