GLENDORA, CA - A nursing facility failed to properly monitor a resident experiencing dangerously low oxygen levels during an overnight shift, ultimately requiring emergency hospitalization the following morning, according to a recent state inspection.
Critical Monitoring Gaps During Medical Emergency
Gladstone Sub-acute and Rehab Center in Glendora faced violations after failing to monitor a resident's oxygen saturation levels following a documented change of condition on January 16, 2025. The resident, who had congestive heart failure, end-stage renal disease, and required hemodialysis, experienced oxygen saturation levels that dropped to 85 percent - well below the normal range of 95-100 percent.
According to facility records, the resident initially required oxygen support through a nasal cannula, with levels gradually increased from 2 liters per minute to 4 liters per minute to stabilize oxygen saturation at 96 percent. The resident's responsible party reported being at the facility around 5 p.m. on January 16 when oxygen levels dropped, stating they "was able to calm Resident 1 and Resident 1's O2 saturation was then better at 95%."
Despite this documented medical emergency, the overnight Licensed Vocational Nurse assigned to monitor the resident failed to check or document oxygen saturation levels during the critical 11 p.m. to 7 a.m. shift. By 8:15 a.m. on January 17, facility staff called 911 and transferred the resident to the hospital for low oxygen saturations, low blood pressure, and altered level of consciousness.
Medical Significance of Oxygen Monitoring
Oxygen saturation levels below 90 percent indicate hypoxemia, a potentially life-threatening condition where insufficient oxygen reaches the body's tissues. For residents with heart failure and kidney disease, maintaining adequate oxygen levels is critical as these organs are already under stress. The heart cannot pump effectively when deprived of oxygen, while compromised kidneys struggle to filter toxins from the blood.
When a resident experiences a change of condition involving respiratory distress, continuous monitoring becomes essential. Low oxygen levels can rapidly deteriorate, leading to confusion, organ damage, or cardiac arrest. Early detection through regular vital sign checks allows staff to adjust oxygen therapy, reposition residents, or seek emergency medical intervention before conditions become life-threatening.
The combination of congestive heart failure and end-stage renal disease creates a complex medical situation where fluid can accumulate in the lungs, making breathing difficult. Regular oxygen monitoring helps detect early signs of fluid overload or cardiac decompensation, conditions that require immediate medical attention.
Facility Policy Violations and Required Documentation
The facility's own policies required Licensed Nurses to complete "Alert charting" for 72 hours following any acute change of condition. This documentation should describe the resident's condition using objective observations and detail staff responses to changes. The Assistant Director of Nursing confirmed that nurses should have monitored the resident's condition each shift, checking oxygen saturation at least every two hours.
According to the facility's Documentation - Nursing policy, Alert charting must track medical events and include descriptions of what staff observe, hear, and feel about the resident's condition. The policy specifically requires documentation of how residents respond to interventions - critical information for continuity of care across nursing shifts.
The overnight Licensed Vocational Nurse acknowledged during interviews that they "did not document the monitoring of Resident 1's O2 saturation during LVN 1's shift" and stated they "did not know if LVN 1 needed to document each shift regarding the monitoring of a residents' change in condition."
Delayed Diagnostic Services Compound Care Issues
Inspectors also found the facility failed to ensure timely completion of a chest X-ray ordered by the resident's physician on January 16. Chest X-rays are crucial diagnostic tools for residents with heart failure and respiratory distress, as they can reveal fluid accumulation in the lungs, enlarged heart chambers, or other complications requiring immediate intervention.
The delay in obtaining ordered diagnostic imaging potentially prevented medical staff from identifying the underlying cause of the resident's deteriorating condition. For residents with complex medical conditions like heart failure and kidney disease, timely diagnostic testing helps guide treatment decisions and prevent complications.
Industry Standards for Change of Condition Monitoring
Nursing home regulations require facilities to monitor residents experiencing health changes and document their condition regularly. When residents show signs of respiratory distress or cardiovascular instability, industry standards call for increased monitoring frequencies - typically every two hours or more often depending on severity.
Proper change of condition protocols should include immediate physician notification, increased monitoring frequency, detailed documentation, and consideration of transfer to higher levels of care when conditions deteriorate. The failure to follow these protocols can result in delayed recognition of medical emergencies and poor outcomes for vulnerable residents.
Additional Issues Identified
The inspection revealed the resident required extensive daily assistance due to moderate cognitive impairment and physical limitations. The facility admitted the resident on January 7, 2025, just nine days before the documented medical emergency, highlighting the importance of establishing robust monitoring protocols for newly admitted residents with complex medical conditions.
The violations carry minimal harm classifications but represent significant gaps in basic nursing care standards that could have resulted in more serious consequences for the resident's health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gladstone Sub-acute and Rehab Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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