Based on review of facility policy and clinical record review, it was determined that the facility failed to follow physician's orders and timely notify the physician of a significant change in condition for one of 18 residents reviewed, resulting in actual harm of Hypoxia (the body is deprived of adequate oxygen supply at the tissue level) for Resident 8. Findings include: Review of facility policy, Notification of Condition Changes, last revised April 19, 2023, revealed the facility would notify the resident's provider when there is a significant change in the resident's condition, abnormal test results, and/or a need to alter treatment significantly. Review of Resident 8's physician's orders revealed an order dated November 20, 2023, for oxygen 3 liters (L) nasal cannula every shift for shortness of breath and hypoxia (low oxygen levels). The order further stated that nursing may titrate (adjust) oxygen to keep the resident's oxygen saturation above 90%. Review of Resident 8's progress notes revealed a nursing note dated November 20, 2023, (6:00 p.m.) which indicated: Resident's o2 [(oxygen)] read 78 [(normal is 95-100)] and resident refused to wear oxygen cannula. After dinner, resident's o2 read 57 and continue to refuse to wear cannula. Resident was convinced to wear it but stated she will remove it shortly. Additional review of Resident 8's clinical record failed to reveal any documented evidence the physician was notified of the resident's low oxygen saturation levels or the resident refusing to wear the oxygen cannula. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8' progress notes revealed a nurse's note dated November 21, 2023, at 5:03 a.m. which indicated: Resident's [pulse oximetry] was 87% with o2 at 2L. Resident refused [head of bed] to be raised. Staff continues to educate resident about the [pulse oximetry] level she should be at and how to achieve that goal. Resident has audible wheezing and is [short of breath.] Will continue to follow plan of care. Further review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels, wheezing, or shortness of breath. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Review of Resident 8's clinical record revealed a nurse's note on November 22, 2023, at 5:46 a.m. which indicated: Resident found sitting in recliner leaning to the left with eyes closed without o2 cannula. At this position resident [pulse oximetry] was 67%. Resident difficult to arouse. When applying o2 cannula, [pulse oximetry] increased to 87% on 2L o2. A few minutes later resident woke up gasping with [shortness of breath,] frantic, and confused. Gave resident education about leaving o2 cannula on and explanation. Resident agreed to leave it on. Will continue to follow plan of care. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 5:27 a.m. which stated: Resident lying in bed [pulse oximetry] was 65%. When [Resident 8] sat on the side of bed [pulse oximetry] increased to 83%. Resident was encouraged to take deep breaths and cough but no further improvement. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 11:25 a.m. which stated: Resident away from home with family for thanksgiving dinner and left facility at 11:25. Resident's pulse ox was 83% on 3L of o2 via [nasal cannula.] Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note date November 23, 2023, at 10:20 p.m. which indicated: Resident's o2 fluctuated throughout the shift. At one time it read 49% when returning from an outing with family. After o2 cannula placed on resident, [his/her] o2 raised to 84%. When checked at [bedtime,] resident's o2 read at 72%. Resident appears to only be mouth breathing and cannula is not being used correctly. Resident removes cannula periodically when left alone. Resident is reminded to breathe through nose. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nursing note dated November 24, 2023, at 5:00 a.m. which indicated: Resident noted using abdominal muscles for breathing and experiencing air hunger (difficulty breathing). Unable to raise oxygen saturation more than 83% @3L. The on-call [physician] gave orders to send the resident to [emergency room] for eval. Review of Resident 8's hospital discharge summary revealed the resident was hospitalized in the intensive care unit (ICU) from November 24, 2023 until December 3, 2023, with a diagnosis of acute respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide) and required BiPAP (machine that normalizes breathing by delivering pressurized air via face mask into the upper airway that leads to the lungs. Its bilevel design means that a BiPAP device provides two different levels of air pressure: one for breathing in and one for breathing out.) The facility's failure to follow Resident 8's physician's orders for oxygen at 3 liters and titrating to maintain oxygen levels above 90% as well as the failure to timely notify the physician of Resident 8's change in condition was discussed with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at approximately 10:40 a.m. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies