Failure to Evaluate and Respond to Change in Condition for Resident with Low Oxygen Saturation
Penalty
Summary
The facility failed to properly evaluate and respond to a change in condition for a resident with a history of infection related to a hip prosthesis, chronic systolic heart failure, and a prosthetic heart valve. The resident had moderately impaired cognitive function and was being monitored for oxygen saturation, with facility parameters indicating that levels below 90% required attention. Over several days, the resident's oxygen saturation levels fluctuated, with multiple documented readings below the facility's threshold, including a reading as low as 54%. Despite these low readings, there was no physician order for oxygen, and staff did not consistently notify a nurse or provider of the resident's declining oxygen saturation. On one occasion, a nurse aide recorded a critically low oxygen saturation but became busy and failed to report it to the nurse. Other staff members noted low oxygen levels but did not observe respiratory distress and did not escalate the issue appropriately. The situation escalated when dietary staff alerted a registered nurse that the resident was unresponsive, at which point the resident was found without signs of life. Facility policy required detailed observation and provider notification in the event of a change in condition, but this was not followed. Interviews with staff confirmed that expected protocols, such as rechecking oxygen saturation, ensuring oxygen was administered as ordered, and notifying the physician, were not consistently implemented. The failure to recognize and respond to the resident's significant change in condition directly contributed to the deficiency cited in the report.