Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper oxygen administration for three residents, leading to deficiencies in respiratory care. For one resident, there was no physician's order for oxygen therapy, despite the resident receiving oxygen via nasal cannula at 2.5 liters per minute. This resident had severe cognitive impairment, as indicated by a BIMS score of 4. Observations confirmed the absence of a physician's order, which was verified by both an LPN and the Unit Manager. For two other residents, the facility did not administer oxygen as per the physician's orders. One resident, with a BIMS score of 15 indicating little to no cognitive impairment, had a physician's order for oxygen at three liters per minute, but was observed receiving four liters. Another resident, with a BIMS score of 14, was supposed to receive oxygen at three liters per minute but was observed receiving it at two liters. Interviews with the LPN and DON confirmed the discrepancies between the physician's orders and the actual oxygen settings.