Failure to Provide and Document Appropriate Assessment and Oxygen Management During Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards for a resident with multiple comorbidities who experienced a change in condition with hallucinations and hypoxia. The resident had diagnoses including chronic diastolic CHF, chronic kidney disease, type 2 diabetes with neuropathy, and a history of UTI, and was noted to have a POA daughter as responsible party. On the day in question, nursing documentation showed the resident was hallucinating, with vital signs including BP 124/57, HR 66, and SpO2 90%, and the NP ordered oxygen at 2L via nasal cannula with titration to keep SpO2 above 93%, as well as a UA/CS. A change in condition note documented altered mental status with visual hallucinations and the need for UA and oxygen therapy. Despite these orders, there was no documentation of oxygen saturation levels below 90% in the medical record and no additional respiratory assessments by nursing staff were identified. Later that afternoon, a nursing note stated the resident’s daughter called 911 due to concern about hallucinations and that the resident repeatedly removed the oxygen despite redirection, with staff reapplying the oxygen and providing education. The nurse documented that, per family request, the resident was sent to the hospital in “stable condition,” sitting upright, drinking a beverage, and not wearing oxygen at the time of EMS departure. However, the EMS report documented that upon arrival the resident was confused, lethargic, having visual hallucinations, and had an SpO2 of 86% on room air, requiring 15 L/min O2 via non-rebreather to maintain stable saturations. The daughter reported to EMS that staff had told her a UA could not be done on the weekend, and EMS documented they were unable to obtain history from the nurse because she was not present. In interview, the LPN who documented the nursing notes could not recall the resident’s oxygen saturation level that prompted oxygen therapy, could not recall how often rounding was done to ensure oxygen was in place, and did not remember why EMS was not provided with needed medical information. The LPN was unsure whether she had told the family that UAs are not done on Sundays, acknowledged that UAs are in fact obtained on Sundays, and agreed that an SpO2 of 86% on room air is not stable but could not explain why she documented the resident as stable and without oxygen at departure despite the EMS finding of 86% SpO2 on room air. The DON and Administrator confirmed that UAs can be obtained on weekends and that the nurse should have provided EMS with the medication list, face sheet, and advance directives.
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