Failure to Provide Timely Respiratory Intervention for Resident with Low Oxygen Saturation
Penalty
Summary
A resident with a history of COPD, chronic kidney disease, and atrial fibrillation was admitted to the facility and had standing orders for supplemental oxygen to maintain saturations above 89%, with instructions to increase oxygen up to 2 liters before notifying a provider. The resident's care plan directed staff to monitor for breathing difficulties and signs of acute respiratory insufficiency. On the morning in question, the resident was found to have oxygen saturations as low as 64%, which were confirmed by repeated checks. The CNA reported these findings multiple times to both an LPN and the Resident Care Manager/LPN, but the Resident Care Manager delayed addressing the concern, and no oxygen was administered to the resident at that time. The resident was not transferred to the hospital until several hours later, where they were diagnosed with hypoxic respiratory failure. Staff interviews confirmed that the low oxygen saturations were reported and recognized, but appropriate interventions, including the administration of oxygen, were not initiated in a timely manner. Facility leadership acknowledged that the standard of practice would have been to reassess the resident, provide oxygen, and complete a full set of vitals before determining whether to send the resident to the hospital or contact the physician. The lack of timely evaluation and intervention was identified as a deficiency in providing appropriate and timely respiratory care.