The breakdown in respiratory care coordination left nurses documenting treatments they weren't providing while rehabilitation staff conducted separate oxygen trials during business hours only.
Resident #8 arrived from the hospital with discharge orders requiring CPAP use at night and a plan to gradually reduce supplemental oxygen. But the facility's admission orders omitted both requirements entirely.
For nearly a month, from April 9 through May 5, no oxygen weaning occurred at all. Nurses continued signing treatment records indicating 2 liters of oxygen per minute around the clock, along with oxygen weaning orders every shift.
When weaning finally began May 5, rehabilitation staff conducted brief trials during therapy sessions. They would decrease the resident's oxygen or remove it completely while monitoring oxygen saturation levels during physical and occupational therapy.
The rehab notes showed successful trials on May 5, 6, 7, 8 and 9. Staff reduced the resident to 1 liter per minute during sessions and left the oxygen at that lower level afterward.
But nursing staff remained unaware of these changes.
Throughout this period, nurses continued documenting 2 liters of oxygen per minute on treatment records. They signed off on oxygen weaning orders every shift despite having no knowledge of or participation in the weaning plan.
"It's actually more like a trial," rehabilitation staff member #15 explained to inspectors. She described how rehab workers would decrease oxygen levels or remove oxygen entirely while working with residents, monitoring their response during therapy sessions.
The rehabilitation department operates Monday through Friday during daytime hours only. No rehab staff work evenings, nights or weekends.
This created a fundamental gap in care coordination. Nursing staff, who provide round-the-clock coverage, were signing orders for a treatment plan they weren't executing while rehab staff conducted weaning trials only during limited business hours.
When inspectors questioned the Director of Nursing about the missing CPAP and oxygen weaning orders from admission, she said she wasn't sure why they were omitted and would need to check the record.
Asked where staff would document oxygen weaning attempts and the resident's response, she indicated the rehabilitation department handled oxygen weaning. She confirmed rehab staff weren't present during evenings, nights or weekends.
Inspectors pressed further: Why were nursing staff signing off oxygen weaning orders every shift if they weren't involved in the weaning process? Where was Resident #8's oxygen weaning progress documented?
The Director of Nursing said she would have to check and get back to the surveyor.
She never did.
The rehabilitation director discussed residents with the interdisciplinary team, according to staff #15. But this communication apparently didn't reach bedside nurses responsible for documenting and administering respiratory treatments around the clock.
Treatment Administration Records showed oxygen provided continuously at 2 liters per minute. Meanwhile, rehabilitation encounter notes documented successful weaning trials reducing the resident to 1 liter per minute during therapy sessions.
The disconnect meant nurses were documenting one oxygen level while the resident was actually receiving a different amount. More concerning, they were signing orders for oxygen weaning without any involvement in or knowledge of the weaning process.
Federal inspectors found no evidence nursing staff were aware of the oxygen weaning plan despite signing related orders every shift for weeks.
The facility's respiratory care breakdown illustrates how poor communication between departments can compromise patient safety. When nurses document treatments they aren't providing while other staff conduct separate interventions, residents face risks from uncoordinated care.
Resident #8's case revealed systemic problems: missing admission orders, failed interdisciplinary communication, and documentation that didn't reflect actual care provided.
The administrator was notified of these concerns on September 17 at 1:08 PM, the day before inspectors completed their survey.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for King David Nursing and Rehabilitation Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
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