F0684

D

Failure to Obtain Timely Nurse Assessment After Severe Oxygen Desaturation

Lexington, North Carolina Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a nurse was requested to assess a resident who experienced a significant drop in oxygen saturation to 68% on room air. The resident had extensive respiratory and cardiac comorbidities, including end stage renal disease on hemodialysis, COPD, chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder, anxiety disorder, recent sepsis, respiratory acidosis, acute respiratory failure, and a recent NSTEMI. The resident had also been recently hospitalized for influenza and pneumonia and was being monitored for thrombocytopenia. The resident’s care plan included goals to maintain oxygen saturation above 90% and interventions to monitor for signs and symptoms of respiratory distress, decreased pulse oximetry, abnormal breathing patterns, and to report such changes to the physician.

On the evening in question, the resident’s vital signs earlier in the day had been within baseline, with oxygen saturations between 90% and 96%. At approximately 8:00 PM, the NA entered the resident’s room to obtain vital signs and found the resident without oxygen, yelling, and anxious about her health. The NA obtained vital signs and documented an oxygen saturation of 68% on room air. The NA notified the Medication Aide, who was just outside the room. The NA assisted the resident in putting her oxygen back on and rechecked the oxygen saturation, which increased to approximately 91–92% after a few minutes. The Medication Aide also checked the oxygen saturation with a manual oximeter and obtained a reading of 91–92% with oxygen applied. The NA reported that the resident’s color appeared normal and that the resident became calmer after about 10 minutes.

The Medication Aide reported that the resident had been yelling frequently that night, which was typical for her, and had repeatedly removed and thrown down her oxygen tubing. The Medication Aide stated she had been in and out of the room multiple times to re-educate the resident and replace the oxygen. When called by the NA around 8:00 PM due to the low oxygen saturation in the 60s, the Medication Aide found that the NA had already reapplied the oxygen and that the saturation was rising. The Medication Aide confirmed oxygen saturations of 91–92% with oxygen on, administered a scheduled breathing treatment, and continued to check the resident with a manual oximeter several times, noting that the resident appeared normal, with no pallor or cyanosis, and calmer. The Medication Aide did not obtain a full set of repeat vital signs and did not immediately notify the nurse at the time of the 68% reading; instead, she informed the primary nurse shortly before 10:00 PM that the resident’s oxygen saturation had dropped to 68% on room air earlier but had since returned to normal with oxygen.

Nurse #1, the primary nurse for the resident that evening, stated she had assessed the resident at the start of the shift and that the resident’s yelling and calling out were usual for her. Nurse #1 observed that the Medication Aide had been going in and out of the resident’s room to assist with oxygen but was not informed of the 68% oxygen saturation until just before 10:00 PM, approximately two hours after the event. Nurse #1 acknowledged that she did not go into the room when she passed by around 9:30 PM and only visually noted the resident was awake and calmer. She stated that when she was finally notified, she was told the resident had previously desaturated to 68% on room air but was now stable with normal vital signs after oxygen was reapplied and a breathing treatment was given. The Medical Director later stated he was not aware of the desaturation to 68% and would have expected the resident to be checked at that time and to be notified of a new oxygen desaturation level. The deficiency centers on the failure of the NA and/or Medication Aide to request a nurse assessment at the time of the critically low oxygen saturation, despite the resident’s care plan requirements and complex respiratory history.