Failure to Notify Physician of Resident's Respiratory Distress and Oxygen Initiation
Penalty
Summary
A deficiency was identified when the facility failed to consult with a resident's physician after the resident experienced a new onset of shortness of breath and required initiation of oxygen therapy. The resident, who had been admitted with a right femur fracture, was noted by a certified occupational therapy assistant to have labored breathing and an oxygen saturation of 89%, resulting in a shortened therapy session. There was no documentation in the clinical record that the medical provider was notified of this change in condition. Subsequently, nursing staff responded to the resident's complaint of difficulty breathing, observed an oxygen saturation of 88%, and initiated oxygen therapy at 2 liters per minute. Later, emergency medical services were called, and the resident was placed on 5 liters per minute of oxygen via a non-rebreather mask. Interviews with staff confirmed that the resident's complaints and low oxygen saturation were observed and reported among staff, but there was no evidence that the physician was consulted at any point during these events. The deficiency was confirmed through record review and staff interviews, and findings were reviewed with facility leadership during the exit conference.