Failure to Document and Notify Physician After Fall and Low Oxygen Saturation
Penalty
Summary
Staff failed to provide care according to standards of practice for a resident who experienced a fall and subsequently developed low blood oxygen levels. After the fall, the resident was found with injuries including skin tears and a hematoma on the forehead. Although a head-to-toe assessment and neuro checks were initiated, there was a lack of thorough and timely documentation regarding follow-up monitoring and the resident's condition in the days following the incident. The facility's policy required prompt notification of the physician and documentation of changes in condition, but these steps were not consistently followed. The resident, who had a history of pulmonary hypertension, chronic respiratory failure, heart failure, cerebral infarction, and sleep apnea, exhibited significantly low oxygen saturation readings, including a documented level of 72%. Despite facility protocols and physician orders requiring staff to notify the physician if oxygen saturation fell below 90%, there was no documentation that the physician was notified at the time of these low readings. Staff applied oxygen without a physician's order and did not consistently document assessments, interventions, or physician notifications related to the resident's declining condition. Multiple staff interviews revealed confusion about the facility's protocols for oxygen administration and physician notification. Staff reported difficulty obtaining accurate oxygen saturation readings and observed signs of hypoxia, such as bluish fingertips and confusion, but failed to document these findings or notify the physician in a timely manner. The lack of timely and complete documentation, monitoring, and physician notification contributed to a delay in appropriate medical intervention for the resident, who was eventually sent to the hospital after further deterioration.