Failure to Provide Adequate Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required supplemental oxygen therapy. The resident, who had a history of respiratory failure, coronary artery disease, renal insufficiency, pneumonia, and sarcoidosis of the lungs, was admitted with a care plan specifying continuous oxygen at 2L, to be increased to 3.5L with ambulation. Despite this, staff changed the oxygen order from scheduled to as-needed (PRN) without increased monitoring or proper consultation with the resident and family. Documentation shows that the resident's oxygen saturation levels were repeatedly below 90% on room air following the order change, and there was a significant decrease in the frequency of oxygen monitoring. Therapy and nursing notes indicated that the resident experienced significant drops in oxygen saturation during therapy sessions, sometimes falling into the low 80s and requiring time to recover. After the order was changed to PRN, the resident's oxygen levels were not checked as frequently, and there was a lack of documentation regarding the rationale for the order change or communication with the family. Staff interviews revealed confusion about who authorized the order change, and the primary care physician was not familiar with the resident or the change. Family members reported that the resident was taken off oxygen abruptly without discussion, and observed him to be lethargic, shaking, and cyanotic prior to hospitalization. Ultimately, the resident was found with oxygen saturations in the low 70s, was placed back on continuous oxygen, and was subsequently hospitalized for shortness of breath, weakness, and pulmonary congestion. Facility policy required that residents and families be informed of new orders, especially those related to changes in condition, and that nurses observe and document signs of respiratory distress. These procedures were not followed, leading to inadequate respiratory care and a negative outcome for the resident.