Failure to Notify Provider and Family of Resident’s Acute Hypoxic Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and family of a significant change in condition following an acute hypoxic event. The resident was newly admitted with intact cognition, chronic lung disease, and orders for CPAP at night and oxygen at 2 L via nasal cannula to maintain O2 saturation above 90%. Baseline assessments documented normal respirations and an oxygen saturation of 96% on room air, with care plan interventions to monitor O2 saturations, watch for cyanosis, administer oxygen as ordered, and keep the physician informed of changes. During combined PT and OT assessments, the resident demonstrated signs of respiratory distress, with therapy documentation noting fluctuating oxygen saturations and lips turning blue. Nursing was notified and the resident was placed on CPAP. Despite these events, progress notes from late morning on one day through the following morning contained no indication that the provider or family were notified of the hypoxic incident. The resident reported that during therapy his oxygen saturation was 66% and that a nurse applied CPAP because there was no oxygen in the room. A family member later learned of the episode directly from the resident and, upon asking staff to recheck, was told the oxygen saturation was 89%, which the family member stated staff had not previously rechecked. Interviews with an LPN, RN, risk manager, NP, and DON confirmed that oxygen saturations of 66% or 89% would be considered low, should have been documented, and should have prompted notification of the provider and family, and that a sudden low oxygen saturation constituted a change in condition. The facility’s Notification of Changes policy required that changes in a resident’s condition be shared with the resident and/or representative and reported to the attending physician, which did not occur in this case.
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