On Nov. 27, 2023, two certified nursing assistants at Azria Health informed the home’s on-duty nurse that a female resident had experienced a significant change in her mental and physical condition. The two CNAs had noticed the woman’s oxygen saturation levels had dropped to 63%, well below the 88% level that typically calls for immediate medical intervention. In addition, the woman’s blood pressure had dropped to 79/39 — a dangerously low level.
When the nurse was notified, she told the CNAs to place the woman on bottled oxygen. The CNAs did so but after 20 minutes, the woman’s oxygen saturation was at 92% — still abnormally low — and the woman was confused and appeared to be in pain. The two CNAs reported their concerns to the nurse again but, according to state inspectors, the nurse did not seem worried or concerned and simply replied, “OK.”
Later in the day, when the woman’s oxygen levels dropped to 72%, the nurse asked the CNAs to increase the flow of bottled oxygen to the resident. The aides allegedly did so and then reported the resident’s vital signs never improved for the rest of their shift.
When the overnight nurse came on duty at 10 p.m., one of the CNAs pulled her aside, told her what was happening and stated the woman needed to go to the hospital. According to inspectors, the overnight nurse agreed and the resident was sent to the emergency room at 10:30 p.m., four hours after the aides had first reported their concerns. Within 24 hours, the resident was dead, with the cause of death listed as congestive heart failure.
Later, in talking to state inspectors, the nurse who was alleged to have been dismissive of the aides’ concerns denied being told any such concerns. When asked if anyone on the staff had told her the woman’s blood pressure was low, the nurse said no. Inspectors alleged that when asked if anyone had reported the woman’s oxygen saturation levels were low, the nurse said no, but then said maybe.
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Care Facility Cited for Ignoring Aides' Concerns Prior to Woman's Death
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