Failure to Implement Care-Planned Stairwell Escort for Oxygen-Dependent Resident
Penalty
Summary
Facility staff failed to implement a care plan intervention requiring an escort when a resident used the stairwell. The resident had been admitted with multiple diagnoses including COPD, chronic respiratory failure with hypoxia, and hypertension. The resident’s care plan, revised on 10/29/25, specified that the resident was to use the stairs when going down and coming back in, with an escort. A physician’s order dated 12/11/25 directed oxygen supplementation of 2–3 L/min via nasal cannula every shift for COPD. A quarterly MDS assessment documented that the resident had an intact BIMS score of 15, experienced shortness of breath with exertion, when sitting at rest, and when lying flat, and used oxygen therapy. On observation in the 2-north stairwell on 01/30/26 at 3:47 PM, the resident was seen alone, going down the stairwell, and was noticeably short of breath. The resident was on 3 L of oxygen via nasal cannula and was carrying a portable oxygen E-tank in a wheeled caddy. The resident stated that he did not like taking elevators and therefore used the stairs, and that a staff member had let him down to the stairwell, which required manual entry of a 4-digit code from the units. In a face-to-face interview shortly afterward, the Administrator acknowledged that the resident used the stairwell due to claustrophobia and stated that the resident should have someone with him when using the stairs, confirming that the care-planned escort intervention was not implemented.
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