F0695

D

Failure to Perform Thorough Respiratory Assessments and Maintain Complete Oxygen Orders

Grand Blanc, Michigan Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not completing thorough respiratory assessments and not maintaining complete oxygen orders for two residents. One resident was admitted with multiple diagnoses including acute respiratory failure and later developed pneumonia, with radiology showing right upper lobe infiltrate and subsequent worsening bilateral opacities concerning for pneumonia. Nursing progress notes documented intermittent cough, shortness of breath (SOB), and use of supplemental O2, but lung assessments were inconsistently documented and often lacked detailed respiratory findings such as lung sounds. Although the resident’s oxygen was discontinued after initial improvement, when oxygen saturations later dropped into the low 80s on room air, oxygen therapy was restarted without a corresponding new physician order being entered into the medical record.

During the period when the resident had pneumonia twice, documentation showed minimal thorough respiratory assessments despite ongoing respiratory symptoms and treatment with antibiotics, inhalers, and nebulizer treatments. Notes indicated low SpO2 readings, increased O2 requirements, and abnormal lung findings such as diminished sounds and wheezing, but the chart lacked consistent, detailed lung assessments across shifts. A skilled care note on one day listed the resident’s respiratory status as “None,” and a sepsis screening completed almost simultaneously indicated no documented infection or antibiotic therapy, which conflicted with the resident’s active pneumonia diagnosis and antibiotic treatment. A nurse working an evening shift reported that she did not assess lung sounds at any time during her shift, including before or after administering a breathing treatment, despite having been told in report that the resident “did not sound too good.”

The sequence of events leading up to the resident’s transfer to the hospital included rising oxygen needs, low oxygen saturations despite increased O2 flow, and abnormal lung sounds described by night-shift staff, but the timing and progression of the change in condition could not be clearly determined from the record due to inconsistent and incomplete respiratory documentation. The Infection Preventionist acknowledged that charting during this period was inconsistent and did not provide an accurate depiction of the resident’s respiratory status, and agreed that lung sounds would have been abnormal given the pneumonia diagnosis. Hospital records later documented that the resident had needed more oxygen than her baseline and was admitted with extensive bilateral pneumonia, acute-on-chronic respiratory failure, and other complications, ultimately leading to death.

A second resident was observed using supplemental oxygen via concentrator, with the device set at 2 L, but the corresponding physician order only stated to provide O2 via nasal cannula to maintain SpO2 greater than 89% and did not specify the liter flow or range. The unit manager confirmed that the liter amount was not listed in the order. This omission meant that the oxygen order for this resident was incomplete, as it lacked a defined flow rate despite the resident having diagnoses including acute respiratory failure with hypoxia, pneumonia, and end-stage disease.