F0695

D

Failure to Provide and Document Ordered Respiratory Services for Multiple Residents

Blackfoot, Idaho Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory services as ordered by physicians and to document nursing interventions in response to low oxygen saturation (SpO2) readings for seven residents. For one resident with disorganized schizophrenia and anorexia, the physician ordered oxygen at 1–2 LPM by nasal cannula as needed to keep SpO2 greater than 90%. The resident’s record showed multiple SpO2 readings of 90% on various dates with no documented nursing interventions. Another resident with anxiety disorder and dementia had an order for PRN oxygen by nasal cannula, titrated 2–5 LPM to keep SpO2 at 90% as allowed. This resident was observed in bed with the O2 regulator set at 2 LPM while the nasal cannula lay on the overbed table, and the record showed several SpO2 readings between 83% and 89% with no timely or documented interventions, except for one instance where an intervention was documented two hours late.

Additional residents with dementia, upper respiratory infection, bipolar schizoaffective disorder, hypertension, paranoid schizophrenia, and obesity had physician orders for oxygen titrated by nasal cannula to maintain SpO2 above 90% as tolerated. Their medical records contained multiple low SpO2 readings, ranging from 85% to 90%, without corresponding documentation of nursing interventions. One resident with bipolar schizoaffective disorder and diabetes had an oxygen order of 2–5 LPM to keep SpO2 at 87–90% as allowed, yet was observed at the nurse’s station without supplemental oxygen and later reported using oxygen only at night or when sitting in his room. This resident’s record also showed several low SpO2 readings, including one as low as 80%, with no documented interventions.

A resident with COPD and dementia had a physician order for oxygen via nasal cannula at 0.5–5 LPM, titrated to keep SpO2 between 88–92% as allowed. The record showed SpO2 readings of 82%, 84%, and 87%, with one nursing intervention documented five hours late and no other interventions recorded for the other low readings. Across all seven residents reviewed for respiratory services, surveyors identified repeated instances where low SpO2 values were recorded without corresponding nursing actions or documentation, despite existing physician orders specifying oxygen parameters. The DON stated that the low SpO2 documentation without documented nursing intervention was due to poor and lacking nursing intervention documentation.