Failure to Monitor Respiratory Status and Administer Oxygen per Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care and monitoring for a resident with significant respiratory risk factors. The resident had diagnoses including nontraumatic subarachnoid and intracerebral hemorrhage, vascular dementia, aphasia, morbid obesity, history of pulmonary embolism, respiratory failure, and a history of tracheostomy. The care plan identified altered respiratory status and required monitoring for signs and symptoms of respiratory distress, including changes in orientation, restlessness, anxiety, air hunger, increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion, and skin color changes, as well as administration of ordered respiratory medications and treatments. On one date in November, progress notes documented new orders to discontinue the resident’s oxygen due to continued refusals, with oxygen saturations reportedly remaining in the 90s and the POA notified. However, from the following day through later in November, there was no documentation that the resident was monitored for respiratory distress or that vital signs and oxygen saturation were checked as outlined in the care plan. On a later November morning, a chest X-ray was ordered to rule out pneumonia, with findings of pneumothorax or pleural effusion and improved depth of inspiration compared to a prior exam, but there were no new orders and no evidence that vital signs, including oxygen saturation, were obtained at that time. Later that same morning, EMS records show the facility called for altered level of consciousness and shortness of breath. EMS found the resident conscious, alert and oriented, with audible crackles and an oxygen saturation of 90% on room air, which improved after oxygen and a DuoNeb treatment. The nurse told EMS the resident was normally on continuous oxygen at 2–4 L/min via nasal cannula and that she had noticed there was no oxygen in the room, and the resident stated she had been off oxygen since the previous night. Facility progress notes documented that the resident was sent to the ED for shortness of breath and later returned with diagnoses of chronic bronchitis and respiratory tract infection, receiving oxygen at 2 L/min, but there were no corresponding physician orders for oxygen from that date through early January. Subsequent documentation of oxygen saturations in late November and December repeatedly showed the resident on oxygen via nasal cannula, often without specifying the liter flow, and on one January observation the oxygen concentrator was running at 3 L/min with the nasal cannula and tubing lying on the floor, while the LPN confirmed there were no current physician orders for oxygen and that oxygen had been administered without orders. The DON and Administrator confirmed the lack of monitoring after oxygen discontinuation and the absence of vital signs when EMS was called.
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