Failure to Notify Provider of Resident's Increased Oxygen Needs
Penalty
Summary
The facility failed to ensure timely notification to a medical provider regarding a resident's change in condition. The resident, who had recently been discharged from the hospital following respiratory failure and was on comfort-focused treatment per their POLST, was ordered to receive oxygen at 2-4 LPM via nasal cannula. On the day in question, the resident was observed to require oxygen via mask at 8 LPM, a significant increase from the prescribed amount. There was no documentation that the medical provider was notified of this increased oxygen need after their earlier visit that day. Staff interviews confirmed that there was an expectation for staff to notify the medical provider of any changes in a resident's respiratory status, including increased oxygen requirements. However, both the Resident Care Manager and the DON were unable to find any evidence that the provider had been informed of the resident's condition change. The nurse on duty believed the provider had already been notified, but this was not substantiated in the records. The resident was later found unresponsive and was pronounced deceased shortly thereafter.