F0580

D

Failure to Notify Physician of Critically Low Oxygen Saturation Levels

Braintree, Massachusetts Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s physician of significant changes in oxygen saturation levels as required by physician orders and facility policy. The facility’s policy on change in a resident’s condition, last revised 02/2021, states that the nurse will promptly notify the attending or on-call physician when there has been a specific instruction to notify the physician of changes in the resident’s condition. Resident #1, admitted in April 2025 with diagnoses including acute on chronic respiratory failure, dependence on continuous oxygen, obstructive sleep apnea, asthma, and schizoaffective disorder, had a physician’s order in December 2025 to obtain oxygen saturation levels every shift and to notify the physician if saturation fell below 90%. Normal oxygen saturation is described as 95–100%, slightly low as 90–94%, low (hypoxemia) as below 90%, and dangerously low as below 88%.

Review of the resident’s oxygen saturation log and MAR from 12/01/25 through 12/29/25 showed multiple dangerously low readings while on 3 L continuous O2 via nasal cannula: 85% on 12/08, 88% on 12/11, 88% on 12/12, 86% on 12/18, 86% on 12/19, 84% on 12/25, and 87% on 12/28. The medical record contained no documentation that nursing staff notified the physician of these low readings, despite the explicit order to do so when levels fell below 90%. In interviews, the assigned nurse stated he was unaware of the parameter to notify the physician and acknowledged he never notified the physician when saturations were below 90%. The Unit Manager and the DON both reported they were not aware that the order included a parameter to notify the physician if oxygen saturation fell below 90%, and the Unit Manager confirmed there were multiple readings below 90% without documentation that the physician had been informed.