Failure to Monitor Oxygen Saturation Every Shift for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that a resident who was dependent on supplemental oxygen had their oxygen saturation (O2 sat) levels checked every shift as ordered by the physician. Observation showed the resident was on 2 liters per minute of oxygen via nasal cannula. Record review revealed that the resident had diagnoses including dependence on supplemental oxygen, cardiomegaly, and a history of myocardial infarction, and was unable to make medical decisions. The resident's orders specified that O2 sat should be monitored every shift to maintain levels at 92% or above, with instructions to titrate oxygen and notify the physician if levels fell below 92%. Review of the resident's O2 sat documentation for the month showed that O2 sat levels were not being checked every shift, with several days in April lacking any recorded measurements. During an interview, an LVN confirmed that the required monitoring was not consistently performed and acknowledged that without regular monitoring, staff would not know if the resident's oxygen needs were being met or if further interventions were necessary. The facility's policy on oxygen administration also required assessment of vital signs and O2 sat while the resident was receiving oxygen therapy.