Failure to Assess and Monitor Resident During Oxygen Therapy After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored while receiving oxygen therapy following a change in condition. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and severe cognitive impairment, experienced vomiting and a decline in oxygen saturation. Although the care plan and physician orders required monitoring of respiratory status and oxygen administration as needed, there was no documentation of ongoing respiratory assessments, monitoring of oxygen saturation, or notification to the physician when oxygen was initiated. The medical record lacked evidence of continued monitoring or documentation of oxygen administration on the medication administration record (MAR) after the resident's condition changed. Staff interviews confirmed that the physician was not notified of the resident's need for oxygen, and nursing staff could not recall details of the resident's respiratory assessments or monitoring. The DON verified the absence of documentation regarding oxygen monitoring and administration. The facility's policy required assessment and documentation during oxygen administration, including lung sounds, oxygen saturation, and the resident's response, but these procedures were not followed. This deficiency affected one resident out of three reviewed for change in condition, with a total of nine residents in the facility receiving oxygen therapy.