**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant decline in status for one Resident (#109) out of a total sample of 27 residents. Specifically, for Resident #109, the facility failed to notify the physician or nurse practitioner when his/her respiratory status declined, resulting in the facility initiating a code blue (emergency response) and the Resident expired. Findings Include: Review of the facility policy titled Physician Notification, undated, included the following but not limited to: -Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. Purpose -To communicate a change in residents condition to physician and initiate interventions as needed/observed. Procedure -A. Upon identification of a change in condition, the Guidelines for Physician Notification may be used as a reference to help determine urgent or routine notification. Clinical judgment and resident baseline should always be the primary determinant of the timing of the physician notification. Resident #109 was admitted to the facility in [DATE] with diagnoses that include acute chronic obstructive pulmonary disease (COPD) with acute exacerbation, respiratory failure with hypoxia (low oxygen level), shortness of breath, acute respiratory infection, parkinsonism, unspecified asthma, dysphagia, and personal history of pulmonary embolism. Review of Resident #109's Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS further indicated that the Resident had debility, cardiorespiratory conditions with a primary pulmonary diagnosis of asthma, (COPD), or Chronic Lung Disease and Respiratory Failure. Review of Resident #109's MOLST (Medical Orders for Life Sustaining Treatment) indicated Resident #109 was a DNR (Do Not Resuscitate), DNI (Do not intubate), but wished to be transferred to the hospital in a medical emergency. Review of Resident #109's progress notes since his/her readmission to the facility on [DATE] indicated he/she had been experiencing an increase in shortness of breath, decline of oxygen saturation levels, increased confusion and use of accessory breathing muscles. Review of Resident #109's active physician orders indicated the following: - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally three times a day related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE]. -Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day related to heart failure. Dated [DATE]. - GuaiFENesin ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE]. - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB related to unspecified asthma. Dated [DATE]. - Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. Dated [DATE]. - Give oxygen 2L via NC if 02 sat is less than 90% as needed for SOB as needed for shortness of breath. Dated [DATE]. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 application inhale orally every 4 hours as needed for COPD Exac. Dated [DATE]. - Skilled Pulmonary Assessment Every Shift every shift related to chronic obstructive pulmonary disease with (Acute) Exacerbation, Asthma. Pulmonary Assessment: lung sounds, SP02, cough and deep breathing exercises. Document finding in progress notes. Lung sound key: C=Clear, R=Rales, Co=Congested, Cr=Crackles, Rh=Rhonchi, Ru=Rubs, W=Wheezes, D=Diminished SOB=SOB while lying flat. Dated [DATE]. Review of Resident #109's respiratory care plan, dated [DATE], indicated the following interventions: - I have altered respiratory status/Difficulty Breathing r/t (related to) aspiration pneumonia. - Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: [DATE]. - Assist me (and my family members PRN) to learn signs of respiratory compromise. Date Initiated: [DATE]. - Elevate HOB until respiratory relief is confirmed - encourage me to limit HOB elevation to 30-45 degrees at baseline. Date Initiated: [DATE]. - Monitor/document/report abnormal breathing patterns to MD (medical doctor): increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Date Initiated: [DATE]. Review of Resident #109's COPD care plan, dated [DATE], indicated the following interventions: -I have COPD exacerbation and asthma. I am S/P (status post) MLOA (medical leave of absence) for respiratory distress, return [DATE]. I was treated for Aspiration PNA Date Initiated: [DATE]. - Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Date Initiated: [DATE]. - Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Date Initiated: [DATE]. - Monitor for difficulty breathing (Dyspnea) on exertion. Remind me not to push beyond endurance. Date Initiated: [DATE]. - Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. Date Initiated: [DATE]. - Monitor/document/report to MD PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Date Initiated: [DATE]. Review of Resident #109's cardiovascular care plan, dated [DATE], indicated the following interventions: - Administer medication as ordered. Date Initiated: [DATE]. - Give oxygen as ordered by the physician. Date Initiated: [DATE]. - Monitor/document/report to MD changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Date Initiated: [DATE]. - Monitor/document/report to MD PRN any s/sx (signs and symptoms) of CAD (coronary artery disease): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refil (refill), colour [SIC] /warmth of extremities. Date Initiated [DATE]. - Vital Signs as ordered and PRN. Notify physician of any abnormal readings (as compared to baseline). Date Initiated: [DATE]. Review of the Nurse Practitioner progress note, dated [DATE], indicated the following: - Has been readmitted from hospital with diagnoses of COPD exacerbation, SOB, pneumonitis/aspiration PNA, acute hypoxic respiratory failure (improved with nebulizers). Continuous on O2 at 2 Liters via NC. O2 Sat running between 95%-96%. He/she is alert with baseline confusion. Lung sounds still wheezy. Received Neb Tx Med (medication) compliant and cooperative with Nx (nursing) care. Assessment and Plan: high risk for respiratory distress, will give 02 prn, monitor 02 sats, nebs/inhalers as indicated. Review of Resident #109's nursing progress note, dated [DATE], indicated the following: -At 5:44 P.M., Patient seems to easily De-Sat (low oxygen saturation) at 86% while on 2L via NC. Oxygen boosted up at 3 Liters to observe if any respiratory improvement occurred, slightly improved, put it up at 88%. Noted, Oxygen saturation slowly increased at a peak of 88% even after Neb treatment administration. Using his/her accessory muscles to breath comfortably, keeping HOB elevated at 45 angles. Patient is alert but very confused, with some fly of ideas noted while conversing with him/her, nonsensical at time. Neb Tx [nebulizer treatment] given as scheduled this shift. Will continue to assess. Oxygen saturation seems to be the prime clinical concern serving this patient. Review of the medical record, failed to indicate staff notified the physician or nurse practitioner of the decline in respiratory status when Resident #109's oxygen saturation dropped to 86%, was using accessory muscles to breathe, and was very confused. Further review of the medical record failed to indicate a physician's order was in place when the nurse increased the oxygen to 3 liters. Review of the Medication Administration Record (MAR) for [DATE] indicated the following: -[DATE], Ipratropim-Albuterol Inhalation Solution was administered as scheduled at 9:00 A.M., oxygen saturation of 88%, at 1:00 P.M., oxygen saturation of 88%. Review of the daytime Pulmonary assessment dated [DATE], indicated: Liter: 2, LS: Wheezing, Min: 15, SOB: Yes, RR: 18, O2 Sats: 88%. Review of the nursing progress note, dated [DATE], indicated the following: -At 4:41 P.M., Initially in the morning resident seemed to be anxious and short of breath. Resident was slightly clammy as he/she stared intensely into caregiver's eyes. No signs and symptoms of infection, even though his/her respiratory rate was elevated and his O2 saturation was 89%. Review of the medical record, failed to indicate staff notified the physician or nurse practitioner of a decline in respiratory status when Resident #109's oxygen saturation dropped to 89% and was clammy and had an elevated respiratory rate. Review of Resident #109's nursing progress note, dated [DATE], indicated the following: - At 7:33 A.M., Alert, responsive and confused. Continues on 2L oxygen therapy via nasal cannula. Patient asking weird questions that make no sense at all. - At 5:05 P.M., Higher peak of O2 Sat throughout the day shift for this patient was 90% on 3 Liters. When the flow returns to the desired order the O2 Sat running between 86%-88% on 2 Liters. No c/o somatic pain, but appears very fatigued, confused, restless at time and weak to even pick up his/her spoon to eat. Review of Resident #109's medical record, failed to indicate staff notified the physician or nurse practitioner of his/her decline in respiratory status when his/her oxygen saturation dropped to 86% to 88% on 2 Liters of oxygen, was documented as very fatigued, confused, restless, weak, and increased the oxygen level to 3 Liters when the physician order is for 2 Liters when the oxygen saturation goes under 90%. Review of the nursing progress note, dated [DATE], indicated the following: - At 5:28 P.M., O2 Sat this shift after Neb treatment running between 88%-90%, continuous O2 at 2L via NC. Lung sounds wheezing, SOB observed upon ADL's. Review of the medical record, failed to indicate staff notified the physician or nurse practitioner of the change in respiratory status when Resident #109's oxygen saturation dropped below 90% on 2 Liters of oxygen and was documented as having shortness of breath and wheezing. Review of Resident #109's nursing progress note, dated [DATE], indicated facility staff initiated a 911 call around 9:08 A.M., when Resident #109 was found unresponsive by nursing staff and was pronounced dead after emergency medical staff arrived. The progress not indicated HCP (Health Care Proxy) notified of change in condition and states he/she will call the funeral home and will pick up Resident's belongings on Thursday. Body released to Funeral home as indicated. During an interview on [DATE] at 10:47 A.M., Nurse #3 said Resident #109 required more oxygen because his/her saturation would drop to the mid to high 80s and sometimes needed 3 Liters of oxygen. Nurse #3 said the providers should have been notified of the change in condition. During an interview on [DATE] at 11:11 A.M., the Nurse Practitioner (NP) said Resident #109 required close monitoring due to his/her fragile respiratory status and said low oxygen levels must be addressed immediately. The NP said nursing staff should have notified him/her immediately of the decline in status, especially because the Resident had recently been sent to the hospital for similar respiratory concerns. The NP said staff should have administered the ordered PRN (as needed) respiratory medications and applied oxygen to prevent oxygen levels from becoming too low. The NP said vital signs should have been documented at a minimum each shift to monitor the Resident's medical status and had the physician or NP been notified, they would determine if the orders should change, or the Resident should be sent to the hospital due to the Residents oxygen levels falling between 86%-90% on 2 Liters of oxygen. During an interview on [DATE] at 11:36 A.M., the Director of Nurses (DON) and the Quality Assurance Nurse said staff should have notified the physician or nurse practitioner of Resident #109's change in condition when it first started. The DON said the Resident was unable to maintain oxygenation above 90% on 2 Liters of oxygen and required an intervention. The DON said the Resident had an order to be sent to the emergency room and the medical record indicated transfer to hospital if needed. The Quality Assurance Nurse said the care plan should have been followed and said it is the expectation of nursing to assess the resident and document a change in condition and notify the physician. Refer to F695

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #109 was admitted to the facility in [DATE] with diagnoses that including acute chronic obstructive pulmonary disease (COPD) with acute exacerbation, respiratory failure with hypoxia (low oxygen level), shortness of breath, acute respiratory infection, parkinsonism, unspecified asthma, dysphagia, and personal history of pulmonary embolism. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated that Resident #109 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required assistance with activities of daily living. Review of Resident #109's MOLST (Medical Orders for Life Sustaining Treatment) indicated Resident #109 was a DNR (Do Not Resuscitate), DNI (Do not intubate), but wished to be transferred to the hospital in a medical emergency. Review of Resident #109's progress notes since his/her readmission to the facility on [DATE] indicated he/she had been experiencing an increase in shortness of breath, decline of oxygen saturation levels, increased confusion and use of accessory breathing muscles. Review of the case management progress note, dated [DATE], indicated the following: -Resident was readmitted to facility on [DATE] with diagnoses of COPD exacerbation, SOB (shortness of breath), pneumonitis/aspiration PNA (pneumonia), acute hypoxic respiratory failure (improved with nebulizers), PMH (past medical history): asthma. He/she reported some SOB on exertion and when lying flat in bed. He/she states that he/she has some difficulty breathing if the HOB is not elevated while lying down and prefers that we leave the HOB (head of bed) in the elevated position at all times to increase comfort and rest. He/she is currently on 2L (liters) oxygen (O2) via NC (nasal canula) and uses Albuterol Sulfate Inhalation Nebulization Solution every 6 hours for SOB and Ipratropium-Albuterol Inhalation Solution PRN (as needed) every 4 hours for COPD exacerbation. The current interventions in place have increased Residents comfort and decreased SOB while lying in bed. Will continue with current interventions with a goal of decrease episodes of SOB and promote comfort and sleep. Review of Resident #109's active physician orders indicated the following: - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally three times a day related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE]. -Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day related to heart failure. Dated [DATE]. - GuaiFENesin ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours related to chronic obstructive pulmonary disease with (Acute) Exacerbation for 5 Days. Dated [DATE]. - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB related to unspecified asthma. Dated [DATE]. - Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. Dated [DATE]. - Give oxygen 2L via NC if 02 sat is less than 90% as needed for SOB as needed for shortness of breath. Dated [DATE]. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 application inhale orally every 4 hours as needed for COPD Exac. Dated [DATE]. - Skilled Pulmonary Assessment Every Shift every shift related to chronic obstructive pulmonary disease with (Acute) Exacerbation, Asthma. Pulmonary Assessment: lung sounds, SP02, cough and deep breathing exercises. Document finding in progress notes. Lung sound key: C=Clear, R=Rales, Co=Congested, Cr=Crackles, Rh=Rhonchi, Ru=Rubs, W=Wheezes, D=Diminished SOB=SOB while lying flat. Dated [DATE]. Review of Resident #109's respiratory care plan, dated [DATE], indicated the following interventions: -I have altered respiratory status/Difficulty Breathing r/t (related to) aspiration pneumonia. - Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: [DATE]. - Assist me (and my family members PRN) to learn signs of respiratory compromise. Date Initiated: [DATE]. - Elevate HOB until respiratory relief is confirmed - encourage me to limit HOB elevation to 30-45 degrees at baseline. Date Initiated: [DATE]. - Maintain a clear airway by encouraging me to clear my own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Date Initiated: [DATE]. - Monitor/document/report abnormal breathing patterns to MD (medical doctor): increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Date Initiated: [DATE]. Review of Resident #109's COPD care plan, dated [DATE], indicated the following interventions: -I have COPD exacerbation and asthma. I am S/P (status post) MLOA (medical leave of absence) for respiratory distress, return [DATE]. I was treated for Aspiration PNA Date Initiated: [DATE]. - Give aerosol (fine mist) or bronchodilators (medication to help breathing) as ordered. Monitor/document any side effects and effectiveness. Date Initiated: [DATE]. - Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Date Initiated: [DATE]. - Monitor for difficulty breathing (Dyspnea) on exertion. Remind me not to push beyond endurance. Date Initiated: [DATE] - Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis (discoloration of skin, lips, nailbeds), Somnolence (drowsiness). Date Initiated: [DATE]. - Monitor/document/report to MD (medical doctor) PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Date Initiated: [DATE]. Review of Resident #109's cardiovascular care plan, dated [DATE], indicated the following interventions: -Administer medication as ordered. Date Initiated: [DATE]. - Give oxygen as ordered by the physician. Date Initiated: [DATE]. - Monitor/document/report to MD changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Date Initiated: [DATE]. - Monitor/document/report to MD PRN any s/sx (signs and symptoms) of CAD (coronary artery disease): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refil (refill), colour [SIC] /warmth of extremities. Date Initiated [DATE]. - Vital Signs as ordered and PRN. Notify physician of any abnormal readings (as compared to baseline). Date Initiated: [DATE]. Review of the Nurse Practitioner (NP) progress note, dated [DATE], indicated the following: -Continuous on O2 at 2 Liters via NC. O2 Sat (saturation) running between 95%-96%. He/she is alert with baseline confusion. Lung sounds still wheezy. Received Neb (nebulizer) Tx (treatment) Med (medication) compliant and cooperative with Nx (nursing) care. Assessment and Plan: high risk for respiratory distress, will give 02 prn, monitor 02 sats, nebs/inhalers as indicated. Review of the nursing progress note, dated [DATE], indicated the following: - Appears with increased confusion. Health Care Proxy (HCP) visited this afternoon expressed concerns regarding his/her current mental status and respiration. This writer offered to send him out, but family member asked to wait on the result. Chest X-ray (CXR) obtained today at 1:20 P.M. Review of Resident #109's medical record indicated a chest X-ray was completed on [DATE] and indicated the following: Congestive heart failure. Right lung base atelectasis (collapse of part of the lung) or pneumonia. A persistent spiculated 2.1 cm (centimeter) nodule in the right upper lobe. Malignancy needs to be excluded. Recommend follow-up further evaluation with CT (computer tomography, type of scan). Review of the nursing progress note, dated [DATE], indicated the following: - HCP was updated on CXR, states nodule is not new MD who follow him/her at (another) Medical center knows about it. NP was also notified of results no new orders at this time due to resident was recently treated for pneumonia, wants MD or regular NP to follow up. Supervisor got in touch with NP, he will see resident on [DATE]. Review of the medical record failed to indicate Resident #109 was seen by the nurse practitioner on [DATE]. Review of the Nursing progress note, dated [DATE], indicated the following: -At 5:44 P.M., Patient seems to easily De-Sat (low oxygen levels) at 86% while on 2L via NC. Oxygen boosted up at 3 Liters to observe if any respiratory improvement occurred, slightly improved, put it up at 88%. Oxygen saturation slowly increased at a peak of 88% even after Neb treatment administration. Using his/her accessory muscles to breath comfortably, keeping HOB elevated at 45 angles. Patient is alert but very confused, with some fly of ideas noted while conversing with him/her, nonsensical at time. Neb Tx given as scheduled this shift. Will continue to assess. Oxygen saturation seems to be the prime clinical concern serving this patient. Review of the medical record failed to indicate the physician or nurse practitioner was notified of the change in respiratory status when Resident #109's oxygen saturation dropped to 86% on 2 Liters of oxygen, was using accessory muscles to breath, was very confused, and increased the oxygen level to 3 Liters when the physician order is for 2 Liters when the oxygen saturation goes under 90%. Review of the Medication Administration Record (MAR) for [DATE] indicated the following: -[DATE], Ipratropim-Albuterol Inhalation Solution was administered as scheduled at 9:00 A.M., oxygen saturation of 88%, at 1:00 P.M., oxygen saturation of 88%. Review of the daytime Pulmonary assessment dated [DATE], indicated: Liter: 2, LS: Wheezing, Min: 15, SOB: Yes, RR: 18, O2 Sats: 88%. Further review of the MAR on [DATE], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB). Review of the nursing progress note, dated [DATE], indicated the following: -At 4:41 P.M., Initially in the morning resident seemed to be anxious and short of breath. Resident was slightly clammy as he/she stared intensely into caregiver's eyes. No signs and symptoms of infection, even though his respiratory rate was elevated and his O2 saturation was 89%. Review of the medical record failed to indicate the physician or nurse practitioner was notified of the change in respiratory status when Resident #109's oxygen saturation dropped to 89% on 2 Liters of oxygen, was clammy and had an elevated respiratory rate. Further review of the MAR on [DATE], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB). Review of the nursing progress note's, dated [DATE], indicated the following: -At 7:33 A.M., Continues on 2L oxygen therapy via nasal cannula. Patient asking weird questions that make no sense at all. -At 5:05 P.M., Higher peak of O2 Sat throughout the day shift for this patient was 90% on 3 Liters. When the flow returns to the desired order the O2 Sat running between 86%-88% on 2 Liters. No c/o somatic pain, but appears very fatigued, confused, restless at times and weak to even pick up his/her spoon to eat. Review of Resident #109's medical record on [DATE], failed to indicate staff notified the physician or nurse practitioner of his/her decline in respiratory status when his/her oxygen saturation dropped to 86% to 88% on 2 Liters of oxygen, was documented as very fatigued, confused, restless, weak, and increased the oxygen level to 3 Liters when the physician order is for 2 Liters when the oxygen saturation goes under 90%. Review of the MAR for [DATE] indicated the following: -[DATE], Ipratropim-Albuterol Inhalation Solution was administered as scheduled, at 9:00 A.M., oxygen saturation of 90%. Further review of the medical record on [DATE], failed to indicate that Resident #109 received any additional nebulizer or inhaler treatments as ordered and only received the one last scheduled dose of Ipratropim-Albuterol Inhalation Solution at 9:00 A.M. as the order was written for 5 days and was discontinued on [DATE]. Further review of the MAR on [DATE], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB). Review of the nursing progress note's, dated [DATE], indicated the following: -At 5:28 P.M., O2 Sat this shift after Neb treatment running between 88%-90%, continuous O2 at 2L via NC. Lung sounds wheezing, SOB observed upon ADL's, skin color is intact. He/she received all his PO (oral) medications including scheduled Neb Tx. Review of the medical record on [DATE], failed to indicate staff notified the physician or nurse practitioner of the change in respiratory status when Resident #109's oxygen saturation dropped below 90% on 2 Liters of oxygen and was documented as having shortness of breath and wheezing Further review of the MAR on [DATE], failed to indicate that Resident #109 was administered any additional medications as indicated, per the physician orders as needed, for the treatment of respiratory distress (or SOB). Further review of the medical record failed to indicate that Resident #109 received any nebulizer or inhaler treatments as ordered by the physician and the last documented administration was on [DATE] at 9:00 A.M. Review of the nursing progress note's, dated [DATE], indicated the following: At approximately 9:08 am, nurse was called to assess Resident. Upon entering in room, Resident was noted lying in bed with breakfast tray in front of him/her. On assessment Resident lying supine, pale and unresponsive with a gasp on tactile stimuli. Oxygen applied. Resident has code status DNR/DNI however may transfer to hospital. Given may transfer status, code blue (emergency response) initiated and 911 was called. Emergency responders in facility, Resident with no pulse, no respiration and no blood pressure. Resident was later pronounced by in house RN. During an interview on [DATE] at 10:48 A.M., Nurse #3 said she walked into the Residents' room and observed Resident #109 in bed laying on his/her back with oxygen on and was unresponsive, so she rubbed the Resident's chest with her hand and the Resident made a loud gasping sound and she applied more oxygen to the Resident. Nurse #3 said she then ran to call 911 and grabbed the Resident's chart because she did not know the code status. Nurse #3 said once she knew the code status, she called 911 because the Resident's wishes are to be transferred to the hospital. Nurse #3 said staff responded and that she did not return to the Resident's room because EMS arrived and the Resident had no pulse and had passed away. Nurse #3 said Resident #109 required oxygen because his/her saturation drops to the mid to high 80's and sometimes needed 3 liters of oxygen. Nurse #3 said she came in at 9:00 A.M. that day to help out the facility and that she did not obtain vital signs that morning because she just arrived. During an interview on [DATE] at 11:11 A.M., the Nurse Practitioner (NP) said Resident #109 required close monitoring due to his/her fragile respiratory status and said low oxygen levels must be addressed immediately. The NP said nursing staff should have notified him/her immediately of the decline in status, especially because the Resident had recently been sent to the hospital for similar respiratory concerns. The NP said staff should have administered the ordered PRN (as needed) respiratory medications and applied oxygen to prevent oxygen levels from becoming too low. The NP said vital signs should have been documented at a minimum each shift to monitor the Resident's medical status and had the physician or NP been notified, they would determine if the orders should change, or the Resident should be sent to the hospital due to the Residents oxygen levels falling between 86%-90% on 2 liters of oxygen. Review of Resident #109's medical record failed to indicate an active physician order to obtain vital signs. Further review of the medical record indicated a physician order for Vital Signs every shift, every shift, was discontinued on [DATE]. During an interview on [DATE] at 11:36 A.M., the Director of Nurses and the Quality Assurance Nurse said staff should have notified the physician or nurse practitioner of the change in condition when it first started and said she would expect staff to follow physician orders for treatment. The DON said the Resident was unable to maintain oxygenation above 90% on 2 Liters of oxygen and required an intervention and said the physician should have been notified and the resident should have been sent to the emergency room for evaluation. The DON said the Resident had an order to be sent to the emergency room and medical record indicated transfer to hospital if needed. The Quality Assurance Nurse said the care plan should have been followed and said it is the expectation of nursing to assess the resident and document a change in condition and notify the physician. During an interview on [DATE] at 1:17 P.M., Resident Representative (RR) #1, who is Resident #109's Healthcare Proxy, said he was concerned about Resident #109's respiratory status because his/her pneumonia diagnosis was not getting better. RR #1 said the recent X-ray indicated a follow up CT scan should be done but it took too long to schedule. RR #1 said staff did not notify him of Resident #109's change in condition and said he didn't expect the Resident to pass away so suddenly because he/she seemed fine prior when visiting. RR #1 said he doesn't know what happened to Resident #109 because it was a sudden change and he was surprised to see Respiratory Failure as the cause of death on the death certificate. Based on observation, record review and interview, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for two Residents (#44, and #109) out of a total sample of 27 residents. Specifically: 1. For Resident #44 the facility failed to, ensure oxygen tubing was changed and dated accurately and ensure the oxygen filter was wiped down. 2. For Resident #109, the facility failed to ensure that a significant change in respiratory status was monitored, assessed, medications ordered by the physician were utilized, and changes in condition were reported timely to the physician for Resident #109; resulting in oxygenation levels falling below parameters, and subsequent death. Findings include: Review of facility policy titled 'Oxygen via Nasal Cannula' dated [DATE] indicated the following but not limited to: - Oxygen therapy via nasal cannula is administered as ordered by a nurse practitioner/physician and includes correct flow rate, mode of delivery and humidification. - Oxygen is set up, delivered and monitored by a licensed nurse or a respiratory therapist. - Nasal cannula labeled with date of initial set-up. 1. Resident #44 was admitted to the facility in [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (COPD). Review of Resident #44's Minimum Data Set (MDS) assessment, dated [DATE], indicated the Resident scored 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was moderately cognitively impaired. The MDS further indicated that the Resident was on oxygen therapy. On [DATE] at 8:57 A.M., the surveyor observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was undated. The oxygen filter was covered with a thick coat of dust. On [DATE] at 7:03 A.M., the surveyor observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was dated [DATE]. The oxygen filter was covered with a thick coat of dust. On [DATE] at 8:18 A.M., the surveyor and Nurse #1 observed Resident #44 wearing an oxygen nasal cannula, the oxygen tubing was dated [DATE]. The oxygen filter was covered with a thick coat of dust. Review of the current physician orders indicated the following: - Date [DATE]: Oxygen tubing and humidifier change every night shift every Wednesday for per protocol and as needed. - Date [DATE]: Oxygen at 2 liters per nasal/cannula every shift for COPD exacerbation. Review of the Resident's oxygen care plan date initiated [DATE] indicated the Resident has oxygen therapy related to COPD. Review of the Treatment Administration Record (TAR) for April indicated the oxygen tubing had been changed on [DATE]. During an interview on [DATE] at 8:13 A.M., Nurse #1 said the oxygen tubing is changed every 24 hours and for the oxygen filter she said maybe the oxygen company does the cleaning. During an interview on [DATE] at 8:40 A.M., Unit Manager #3 said oxygen tubing is changed weekly on the overnight shift and should be dated. The oxygen filter should be wiped down. During an interview on [DATE] at 9:11 A.M., the Assistant Director of Nursing (ADON) said oxygen tubing is changed weekly on the nightshift and the oxygen filter should be wiped down. She said she does all oxygen equipment rounding every week. During an interview on [DATE] at 10:26 A.M., the Director of Nursing (DON) said nursing should change and date the oxygen tubing weekly. The DON said the oxygen company does the filter changes, but nurses can wipe down the filter. The DON said the oxygen company is at the facility weekly and she was not sure if they had cleaned Resident #44's filter.