On 4/19/13, a resident died after the facility failed to keep the resident’s oxygen level greater or equal to 90% per his physician’s order. Multiple nurses failed to evaluate or report the resident’s acute respiratory emergency and rapid deterioration to a physician and registered nurse (RN). One licensed vocational nurse documented life threatening oxygen saturation levels for an hour-long period but did not notify the RN, claiming to be more capable than the RN. A second licensed nurse found the resident unresponsive and without movement but did not evaluate the resident or initiate CPR. The nurse left the room to check on other residents. The resident had been admitted for short-term therapy with plans to return home and had signed a Physician Order for Life Sustaining Treatment (POLST) seeking full treatment and resuscitation in such an event. When EMS was finally contacted and arrived, the resident was without signs of life. EMS responders documented that the staff was not aware that the resident had stopped breathing. He was transported to the hospital where he was pronounced dead upon arrival.

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