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Based on interviews and document review, the facility failed to ensure nursing staff notified patients' physicians after staff discovered patients were not connected to their prescribed oxygen. Additionally, the facility failed to ensure nursing staff documented in the medical record the description of the patient's condition without oxygen treatment, nursing follow-up and patient response to the oxygen treatment when it was resumed for 4 of 10 patients reviewed (Patients #2, #4, #5 and #9).

This failures resulted in an inaccurate patient medical record.

FINDINGS:

POLICY

According to the policy, Reassessment, Patient needs, response to treatments/intervention, and change in condition are to be reassessed as necessary. The Registered Nurse (RN) will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change in the plan of care, and other interventions based on the patient need.

1. The facility failed to ensure nursing staff documented patients who failed to receive their oxygen treatment as prescribed, nursing follow up, and the appropriate notifications in patients' medical records.

a) Review of 4 internal reporting documents for patients who did not receive their prescribed oxygen revealed the following:

On 04/10/17, a Patient Care Technician (PCT) was taking Patient #5's morning vital signs when it was discovered the oxygen treatment was not being delivered to the patient. Patient #5's nasal cannula was in the nose and the tubing was hooked up to the wall oxygen unit, but the oxygen was not turned on. Patient #5's oxygen saturation level ranged between 49% to 88% and Patient #5 reported s/he was lightheaded.

On 01/16/17, a PCT was taking Patient #2's afternoon vital signs when it was discovered the oxygen treatment was not being delivered to the patient. Patient #2 was connected to the portable oxygen tank on the wheel chair, which was empty. The patient was then changed to the wall oxygen unit. Patient #2's oxygen saturation level was at 76%.

On 04/18/17, a Registered Nurse (RN) was performing routine rounding on Patient #4 and noted that the patient looked gray. Patient #4's oxygen saturation level was 80%. Patient #4 had the nasal cannula in his/her nose and the portable oxygen tank was turned. However, the oxygen line was hanging over the back of the wheel chair not hooked up to the oxygen.

On 03/02/17, Patient #9 reported to a PCT that s/he was having a hard time getting enough air. Patient #9 had the nasal cannula in his/her nose but the oxygen was not turned on. Patient #9 was instructed to take several deep breaths after the oxygen treatment was restarted.

Review of Patients #2, #4, #5 and #9's medical records revealed no documentation that an interruption of the oxygen treatment had occurred, the physician was notified, the patient or patient's family were notified, nursing follow-up, and the patients' response to the lack of oxygen treatment administration. This was in contrast to policy.

b) On 06/01/17 at 10:35 a.m., an interview was conducted with Registered Nurse (RN) #6 who reviewed Patient #4's chart for documentation concerning the patient's oxygen treatment. RN #6 reported it appeared there was no documentation of that event. S/he stated, if you did not chart it, it did not happen. RN #6 stated there should have been a progress note or an interdisciplinary note reporting a change in condition, and that the physician and family were notified. RN #6 reported there was a policy requiring nursing staff to document and contact the physician for any change in the patient.

c) On 06/01/17 at 11:27 a.m., an interview was conducted with Patient Care Technician (PCT) #1 who reported a patient should not be left on a portable oxygen tank when they were in their room. The patient was to be hooked up to the wall oxygen unit when in the room. If a patient was found without oxygen in place, the PCT was to document the situation on a progress note and report it to the nurse. PCT #1 stated if a patient went without oxygen, they could become unresponsive or have a seizure as the oxygen was to help them breath.

d) On 06/01/17 at 11:59 a.m., an interview was conducted with RN #2 who also was a house supervisor. RN #2 reviewed Patient #5's chart for documentation on the patient's oxygen treatments. RN #2 reported there was not an interdisciplinary note or a daily nursing assessment note documenting the patient was without oxygen. RN#2 stated if you did not chart it, it did not happen. S/he further stated if something happened to the patient the facility would not know what was done and what intervention was put in place. RN #2 reported not knowing what happened to the patient could affect how the patient received treatment, it could affect the patient going home safely, and it affected the whole plan of care.

e) On 06/01/17 at 3:02 p.m., an interview was conducted with Director of Nursing Operations #3 who stated the expectation was any status change in a patient should be documented in a nursing note; it should be written for any occurrence with the patient. S/he stated the documentation showed they assessed the patient and checked for cognition changes. S/he stated a lack of oxygen treatment would cause harm to the patient. Director of Nursing Operations #3 reported the physician was to be notified for every change in condition and if nursing staff had not written it down on paper than it was not done.

f) On 06/01/17 at 3:39 p.m., an interview was conducted with Director of Compliance #5 who reported the facility was not doing what they were supposed to be doing with oxygen treatments and following policy. S/he stated they needed to keep the patients safe and needed to document how they were doing that.

g) On 06/01/17 at 2:13 p.m., an interview was conducted with Physician #4 who stated if there was any situation or change in condition with a patient, the nurses were expected to let the Physician know. The expectation was all situations were to be documented in the patient chart especially oxygen saturation levels. S/he stated if the physician was not notified of a change the outcome could be serious and could create potential harm to the patient even a cardiac arrest.