Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement physician-ordered supplemental oxygen for a resident, identified as Resident 63, in accordance with professional standards of practice. A physician's order dated November 11, 2024, required staff to administer supplemental oxygen at two liters per minute as needed to maintain oxygen saturation levels above 90 percent. However, a review of the resident's medication and treatment administration records for November 2024, December 2024, and January 2025 revealed that staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. On January 13, 2025, an observation of Resident 63 showed no supplemental oxygen in use, and there was no evidence in the clinical record that staff had assessed the resident's oxygen saturation to confirm that supplemental oxygen was not needed. This deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on January 14, 2025.
Plan Of Correction
1. Resident 63's order was revised to evaluate the need for supplemental oxygen. 2. DON/designee conducted an audit of residents receiving oxygen to verify evaluation is conducted when indicated. 3. Nursing staff will be re-educated on obtaining oxygenation saturation assessments if indicated. 4. DON/designee will audit 5 random residents on oxygen to verify evaluation of oxygenation saturation when indicated weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.