Failure to Document and Intervene for Low Oxygen Saturation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate appropriate competencies in managing oxygen therapy for a resident with multiple diagnoses, including anxiety disorder and dementia. The resident had a physician's order for oxygen via nasal cannula at 2-3L to maintain oxygen saturation (SpO2) above 90%. Despite this order, there were multiple documented instances where the resident's SpO2 levels fell below the prescribed threshold while on oxygen, and no nursing interventions were documented in response to these low readings. The report details several occasions over a period of months where SpO2 values ranged from 84% to 89% while the resident was receiving oxygen, with no evidence that licensed nurses took action or documented any interventions, except for one instance where a nurse instructed the resident to take deep breaths. The Director of Nursing confirmed that staff should have documented interventions for each low SpO2 reading but did not. This deficiency was identified for four out of fifteen licensed nurses and had the potential to affect all residents assessed for oxygen therapy.