**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the physician was consulted regarding a signification change in respiratory status and failed to notify the physician of the need for oxygen administration orders related to oxygen levels and obtain timely a needed seasonal allergy and asthma medication for 1 of 4 sampled residents (Resident 1) reviewed for notification of changes including a significant change in resident health status. Resident 1 experienced harm when hospitalization and intubation was required for respiratory failure related to untreated respiratory symptoms. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . A facility policy, dated [DATE], and entitled Respiratory Care; Oxygen Administration documented the following: -- Oxygen is administered per physician order. Oxygen may be administered in the absence of a physician order in emergency situations. -- Oxygen saturations are obtained and documented as ordered by the physician. In the event of an emergency, and/or clinical assessment indicates a change in respiratory function, oxygen saturations are obtained without a physician order. -- Staff members observe and report signs and symptoms of abnormal respiratory function. These may include but aren't limited to: a. Labored breathing b. Tachycardia (heartbeats faster than usual) c. Restlessness d. Nausea e. Headache f. Dizziness g. New or increased anxiety h. New or increase mental confusion i. Cyanosis (bluish skin color due to decreased amount of oxygen) j. Acute change in level of consciousness. Resident 1 was admitted to the facility on [DATE] with diagnoses including moderate persistent asthma with status asthmaticus, a disease process that affects lung function and causes difficulty breathing and coughing every day. The Minimum Data Set assessment, dated [DATE], documented the resident was alert and oriented to person, place, time, and situation. Review of Resident 1's [DATE] Medication Administration Record (MAR), for [DATE] at 8:28 PM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with status asthmaticus. Guaifenesin cough syrup was administered for congestion. Resident 1's [DATE] MAR, for [DATE], at 7:31 PM, showed Flonase Suspension Spray was administered for wheezing with moderate persistent asthma with statis asthmaticus. Resident 1's [DATE] MAR, for [DATE] at 7:00 AM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with statis asthmaticus. Guaifenesin cough syrup was administered for congestion. No documentation of physician notification of respiratory symptoms was located related to continued symptoms after medications were administered. Resident 1's [DATE] MAR, for [DATE], at 5:19 PM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with statis asthmaticus. No documentation of physician notification of respiratory symptoms was located. Resident 1's [DATE] MAR, for [DATE], showed no documentation for administration of any respiratory medications needed for allergies or moderate persistent asthma with statis asthmaticus. Progress note, dated [DATE] at 3:23 PM, showed Staff C, Licensed Practical Nurse (LPN), documented Resident 1 asked for her blood sugars and blood pressure to be checked as she felt something was off. Blood sugar was 217 and blood pressure was 132/64. Resident had stated her seasonal allergies got bad in the spring and had requested allergy medications Flonase and Allegra, and asthma medication Albuterol. Oxygen saturations (O2 sats) were checked and were 89%. Resident 1 was placed on Oxygen at 2 liters per minute via nasal cannula. The note showed at 3:45 PM, O2 sats were 95%. Resident 1 stated she felt better. Normal O2 saturations are 95% or above. (No documentation of physician notification of respiratory symptoms or oxygen orders were located.) Progress note, dated [DATE] at 6:45 PM, showed Staff D, LPN, documented Resident 1 with nasal congestion and moist cough. Resident 1 reported bringing up clear and whitish phlegm (which can be an indicator of infection). Lungs slightly rattly which cleared with cough. Blood Pressure 117/51, Pulse 73, Temperature 97.4, and O2 sats 96% on 2 liters of oxygen. Resident was requesting Advair inhaler, a medication used to treat asthma. A fax was sent to the physician requesting the Advair inhaler. (No documentation of physician notification of respiratory symptoms was located.) Progress note, dated [DATE] at 1:53 AM, showed Staff E, LPN, documented Resident 1 had cough but no shortness of breath. O2 sats were 94% and temperature was 97.9. Progress note, dated [DATE] at 8:00 AM, showed Staff F, LPN documented Resident 1 was found to be unresponsive and pale with O2 sats of 70% on 2 liters of oxygen. O2 increased to 4 liters per minute. O2 sats increased to 78%. Resident unresponsive to touch and 911 called. On [DATE] at 9:17 AM, Staff E, LPN, said she was the nurse caring for Resident 1 prior to the morning ([DATE]) she was sent to the hospital. Staff E said it was policy to have a physician order for oxygen and monitoring of oxygen saturation levels. Staff E said she thought a prior shift had called the physician to request orders. At 9:20 AM, Staff D, LPN, said on [DATE] Resident 1 had looked poorly. Her O2 saturations were in the 90's. Staff D said Resident 1 had asked for an inhaler called Advair that she used to manage seasonal allergies and asthma. Staff D said another nurse had faxed an order but there had been no response. When asked what the process would be if the facility had not received a response from the physician, Staff D said she wasn't sure, maybe fax again. Staff D said she had not re-faxed or called the physician regarding Resident 1's request for an Advair inhaler, oxygen orders, or Resident 1's respiratory symptoms. At 1;51 PM, Staff F, LPN, said when a resident was placed on oxygen emergently it was facility procedure to call and report conditions to the physician and to obtain orders for oxygen flow rate and oxygen saturation monitoring. On [DATE] at 8:58 AM, Resident 1 said she never did receive the Advair inhaler she requested for her seasonal allergies and asthma. Resident 1 said she received the Flonase inhaler, Allegra tablet, and Albuterol inhaler but what was needed was the Advair inhaler. Resident 1 said she utilized the Advair inhaler every year in the spring when plants began to [NAME] and then again in the fall. Resident 1 said the facility had the medication, but it had expired. An order had been faxed but there had been no reply prior to her being sent out to the hospital. Resident 1 said she did not remember being transported to the hospital on [DATE]. When she awoke, she was told she had received too much oxygen. Resident 1 said she was able to take the oxygen in but not breath it out causing her to retain carbon dioxide. Resident 1 said she went into respiratory distress and had to be intubated. Reference WAC 388-97-0320 (1) .