Failure to Notify Provider of Significant Change in Resident's Oxygen Status
Penalty
Summary
The facility failed to ensure prompt notification of a provider following a significant change in a resident's condition. According to the facility's policy, nurses are required to immediately notify the resident's physician and representative of any significant changes in the resident's medical, mental, or psychosocial status. In this case, a resident with multiple complex diagnoses, including chronic kidney disease, respiratory failure, and pulmonary edema, experienced a dangerously low oxygen saturation level of 84% while on oxygen therapy. Nurse #2 increased the resident's oxygen flow rate and documented the event in the medical record and physician's folder but did not directly notify the physician or nurse practitioner of the change in condition. Interviews with the physician, nurse practitioner, unit manager, and director of nursing confirmed that none were informed of the resident's hypoxic episode or the need for increased oxygen support. All staff interviewed stated that such a change in condition should have been reported immediately to the provider. Review of the medical record showed no documentation of provider notification regarding the resident's low oxygen saturation or the adjustment in oxygen therapy, constituting a failure to follow facility policy and ensure timely provider awareness of a significant clinical change.