Failure to Monitor and Document Oxygen Therapy for Resident with Respiratory Failure
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with complex respiratory needs, including chronic respiratory failure, COPD, and heart disease. Despite physician orders specifying oxygen therapy parameters and the need to avoid excessive oxygen due to CO2 retention, nursing staff did not consistently document the oxygen flow rate or the resident's response to oxygen therapy. The medical record lacked ongoing monitoring of oxygen saturations, even as the resident experienced repeated drops below 92%, increased shortness of breath, and a critically high CO2 lab value. The resident's ability to participate in therapy declined, and she developed new symptoms such as fatigue, headache, and lower extremity edema in the days leading up to her hospitalization. Interviews and record reviews revealed that staff did not maintain adequate documentation or monitoring practices as required by facility policy and professional standards. The resident's care plan and physician orders called for close observation of respiratory status and oxygen therapy, but nurses failed to record essential information such as the method and flow rate of oxygen delivery, as well as the resident's response to interventions. Multiple staff members, including the DON and NP, acknowledged the importance of this documentation and monitoring, but it was not consistently performed or recorded in the electronic medical record. The resident ultimately experienced a significant decline, with oxygen saturations dropping as low as 54% and visible signs of respiratory distress, prompting emergency transfer to the hospital. Hospital records confirmed diagnoses of acute and chronic hypoxic and hypercapnic respiratory failure and CHF exacerbation. Family and therapy staff reported concerns about the resident's deteriorating condition and the lack of timely escalation or intervention by facility staff. The facility's own oxygen administration policy required documentation of oxygen therapy details and resident response, which was not followed in this case.