F0684

E

Failure to Obtain Timely Oxygen Orders and Monitor Change in Condition for Hospice Resident

Tucson, Arizona Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely care and services, including physician notification and obtaining a physician order for oxygen, in response to a resident’s change in condition. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer. A care plan focus initiated shortly after admission identified an alteration in gastrointestinal status due to a colostomy, with an intervention to monitor vital signs as ordered and notify the provider of significant abnormalities. Despite this, the clinical record contained no physician order for vital sign monitoring, and the admission MDS showed no oxygen therapy in the 14 days prior to or at admission.

Oxygen saturation logs for January showed readings in the mid-90s on room air on several dates, but hospice documentation later recorded a decline. Hospice notes indicated that on one visit the resident was lethargic and nonverbal with an oxygen saturation of 93% on room air, and on a subsequent visit the resident was difficult to awaken, lethargic, and reported not feeling well, with an oxygen saturation of 90% on room air. The hospice note for that visit stated that oxygen was ordered and that the resident was added to a decline list, but there was no evidence of a corresponding physician order for oxygen in either the hospice records or the facility’s medical record on that date. A physician order from that date only authorized emergent PRN nursing visits due to change in decline status. Later hospice documentation recorded an oxygen saturation of 87% on room air, noted that oxygen was applied at 2L via nasal cannula after staff filled the concentrator’s water reservoir, yet there was still no physician order for oxygen in the clinical record on that date.

Surveyors found that the facility’s MAR/TAR documented blood pressure, temperature, pulse, and respirations every day and night shift, but did not include oxygen saturation monitoring until several days after the hospice note documenting hypoxia. The electronic medical record showed no oxygen saturation documentation between mid-January and the date when an oxygen order was finally entered. Observations showed the resident in bed with an oxygen concentrator present and turned on at 2L, initially with the nasal cannula draped over the concentrator and later with the cannula in place, before a physician order for oxygen was documented. Interviews with an LPN revealed there was no hospice binder for the resident, no oxygen order or oxygen care plan in the EMR at the time oxygen was observed in use, and that the nurse first became aware the resident was on oxygen during the surveyor’s observation. The ADON and DON both stated that any new need for oxygen or hypoxic episode should prompt immediate physician notification, a physician order for oxygen and change-of-condition monitoring, and oxygen saturation checks every shift, and that oxygen should only be administered with a physician order except as an emergency measure until an order is obtained. Review of facility policies on vital signs, change of condition reporting, oxygen administration, physician orders, and hospice/end-of-life care confirmed that changes in condition were to be promptly communicated to a physician, documented, and incorporated into the care plan, and that oxygen therapy was to be administered and documented only under appropriate physician orders, which did not occur in this case until several days after hypoxia and oxygen use were documented by hospice.

Additionally, hospice staff interviews and records showed that hospice communicated via emailed documentation and that each hospice resident should have a hospice binder at the nurses’ station containing hospice notes and updates. For this resident, there was no hospice binder available, and hospice notes from key visits were not uploaded into the facility’s EMR at the time of review. The hospice RN who visited the resident on the date hypoxia was documented reported that the resident was hypoxic with oxygen saturation around 88–90%, that an oxygen concentrator was already at the bedside when she arrived, and that she notified facility staff that the concentrator’s distilled water reservoir was empty. The DON stated she believed the resident was placed on oxygen by hospice on the morning of the date the order was eventually written and that the oxygen was for comfort measures, and she was not aware of any hypoxic episodes. Review of the clinical record with the DON confirmed that there was no documentation that a provider was notified of a change in condition related to hypoxia and that the first oxygen order was not entered until that same day, despite earlier hospice documentation of hypoxia and oxygen use.