Failure to Monitor and Notify Physician After Resident’s Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and notify a physician of a change in condition for one resident and to document follow-up assessments after initiating supplemental oxygen. The resident was an elderly female with dementia, dysphagia, and chronic kidney disease who had recently been treated with antibiotics and prednisone for walking pneumonia. On 1/7/26 at 2:10 PM, an RN documented that the resident’s SpO2 was 82% during a breathing treatment, that the resident attempted to eat breakfast and did not want to continue the treatment, and that oxygen was applied and tolerated. However, there was no documentation of repeat vital signs or oxygen saturation after the administration of supplemental oxygen, and the RN acknowledged in interview that she believed she had entered follow-up information but it was not present in the EMR. She also confirmed she began oxygen without a physician’s order, relying on standing orders, and recalled use of an oxygen mask that was not documented. On 1/8/26 at 11:35 AM, an LPN documented that the resident’s oxygen saturation dropped with oxygen titration after finishing the course of antibiotics and prednisone for walking pneumonia, and that the resident had decreased appetite, weakness, and was sleeping during the shift, and stated she wanted to go to the hospital. The LPN contacted the medical director, who ordered transfer to the ER, but could not recall who ordered the titration of supplemental oxygen and suggested it may have been something they “just tried” or possibly directed by the ADON. Review of the EMR showed an order for oxygen at 8 L/min via nasal cannula starting 1/7/26, but no repeat vital signs were documented after the change in condition. The DON stated she expected to see follow-up documentation, including repeat vitals and physician notification if the condition did not improve, and clarified that standing orders allowed only up to 2 L of oxygen without a physician’s order and that titration should occur only under physician direction. Facility policies required initiation of 2 L O2 and physician notification if SpO2 was below 89%, and prompt physician notification for significant changes in condition requiring alteration of medical treatment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.