Failure to Follow Provider Orders and Monitor Resident After Hypoxic Event
Penalty
Summary
The deficiency involves the facility’s failure to follow provider orders and comprehensively assess and monitor a resident with chronic lung disease on admission and after a significant change in condition. The resident’s admission MDS indicated intact cognition, no need for oxygen or respiratory devices, and a diagnosis of chronic lung disease. The baseline care plan identified an alteration in oxygen/gas exchange with interventions to monitor oxygen saturations as ordered and PRN, monitor for cyanosis, document respiratory status, administer oxygen as ordered, and keep the provider informed of changes. Provider orders directed staff to monitor vital signs every four hours for 24 hours after admission, assess pain every shift, chart the resident’s condition in nurse’s notes every shift for seven days, check oxygen saturation levels every shift, and complete Daily Skilled Notes on specified shifts and days. Despite these orders, documentation showed that vital signs and oxygen saturation levels were not obtained and recorded as ordered. Oxygen saturation was recorded at admission and at several subsequent times, but there were gaps, including no oxygen saturation assessments documented for the 3–11 p.m. shift on the day of admission and incomplete vital sign sets at later times. The vital sign records did not show monitoring every four hours for 24 hours as ordered. The January Treatment Administration Record lacked evidence that vital signs were entered at the ordered times and that Daily Skilled Notes were completed on certain shifts. Progress notes between admission and the following morning lacked documentation of additional oxygen saturation assessments, Daily Skilled Notes, and nursing assessments on specific dates. The February TAR also lacked documentation of pain assessments every shift, nurse’s notes every shift for seven days, oxygen saturation checks every shift, and completion of Daily Skilled Notes as ordered. The resident experienced episodes of respiratory distress during PT and OT evaluations, with therapy documentation noting fluctuating oxygen saturations, lips turning blue, and placement on CPAP, but the medical record did not reflect decreased oxygen saturation levels corresponding to these events. The resident reported that during therapy his oxygen saturation was assessed at 66% and CPAP was applied, and a family member reported being told later that his oxygen saturation was 89%, with delays in staff responding to requests to recheck his vital signs and no oxygen equipment in the room until the next day. Facility staff, including an LPN, an RN, the NP, and the DON, acknowledged that the medical record lacked documentation of the hypoxic event, associated nursing interventions, provider notification, family notification, and the increased assessments that should have followed a change in condition, as well as acknowledging that ordered vital sign monitoring, oxygen saturation checks, and daily charting were not completed. Requested policies for assessment, monitoring, and following orders were not provided.
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