F0695

G

Failure to Maintain Ordered Oxygen Saturation and Flow for Resident With COPD

Bridgeview, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain ordered oxygen saturation parameters for a resident with COPD and chronic respiratory needs. The resident’s hospital discharge paperwork documented a principal problem of acute on chronic respiratory failure with hypoxia and hypercapnia and COPD with acute exacerbation, with an increased oxygen demand in the emergency department and eventual weaning back to baseline supplemental oxygen needs. The discharge medication list did not specify the oxygen amount to be administered upon discharge, and the facility relied on nurse-to-nurse report to obtain oxygen orders. The physician order sheet at the facility documented that oxygen saturation was to be checked every shift and kept above 93%, with oxygen at 3–4 L/min via nasal cannula continuously.

On the morning of the incident, a nurse’s note documented the resident as alert and oriented, with non-labored breath sounds, oxygen at 4 L/min via nasal cannula, head of bed elevated, and SpO2 at 97%. Later, EMS was dispatched for breathing problems. The EMS run sheet documented that upon arrival, the crew found the resident pale, with labored, tachypneic breathing, in respiratory distress, and on 3 L/min of oxygen via nasal cannula, with an SpO2 of 80%. The EMS crew reported that the RN stated the resident was on 3 L/min of supplemental oxygen but was not aware of the resident’s baseline oxygen status or whether 3 L/min was the baseline amount. The family at bedside reported the resident was usually on 6 L/min via nasal cannula and 10 L/min of BiPAP, and also indicated that when the resident arrived the previous day, the facility did not have the resident’s medications, BiPAP, or correct oxygen orders.

The complainant reported that when the resident was assessed, the resident was slow to respond, pale, and had difficulty breathing, and that an unnamed nurse confirmed the resident was on 3 L/min of oxygen. The complainant stated the resident was then placed on 6 L/min of oxygen and improved immediately. The EMS run sheet documented that after the crew increased the oxygen to 6 L/min, the resident’s breathing rate and effort normalized, skin color returned to normal, SpO2 increased to 93%, and responsiveness improved. The DON stated that the resident’s oxygen order was not sent with the discharge paperwork but was given in nurse-to-nurse report, that the resident was to be on 3–4 L/min via nasal cannula with a goal to maintain oxygen level above 93%, and that the orders were verified with the physician and entered into the computer. The DON also stated that the nurse did not assess the resident because the resident refused, and that if a resident complained of chest pain, he would expect the nurse to stay with the resident. The nurse identified as the discharging nurse reported that the resident had oxygen via nasal cannula but could not recall the liter flow, stated that vitals were within normal limits but could not recall them, and that the resident was not in distress, while the electronic record contained no documented vitals for that shift. The facility’s oxygen administration policy stated that oxygen is to be provided to maintain saturation levels as needed and as ordered by the attending physician.