Failure to Notify Physician of Change in Condition Requiring Oxygen Administration
Penalty
Summary
The facility failed to notify the physician of a change in condition for two residents who required administration of oxygen. In the first case, a male resident with a history of stroke, dysphagia, and mild cognitive impairment experienced shortness of breath with oxygen saturation dropping to 87-89%. Nursing staff administered oxygen as ordered, but there was no documentation that the provider was notified of this change in condition, nor was there documentation of how long the resident required oxygen. The Director of Nursing confirmed that this met the criteria for a condition change and that the provider should have been notified. In the second case, another resident complained of shortness of breath and was administered oxygen, resulting in improved oxygen saturation. The event was recorded in the facility's communication book, but not in the resident's electronic medical record, and there was no documentation of notification to the on-call physician, despite a physician's order requiring notification if oxygen was applied or increased. The facility's policy requires notification of the attending physician for significant changes in a resident's condition or when medical treatment is altered. These failures were confirmed through interviews and record reviews.