Failure to Provide Ordered Oxygen Therapy and Monitor Pulse Oximetry
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including pneumonia, chronic kidney disease, and peripheral autonomic neuropathy, did not receive oxygen therapy as ordered by the physician. The physician's order specified that the resident should receive 2 liters of oxygen as needed for shortness of breath or if oxygen saturation fell below 93 percent, and that oxygen saturation should be recorded. The resident's care plan also included interventions to provide supplemental oxygen as ordered for respiratory issues and anemia. During an observation, the resident was found in bed with the oxygen machine on and the nasal cannula placed on the bed rather than connected to the resident for over 30 minutes. Staff present, including an LVN, CM, and RN, confirmed that the resident should have been receiving oxygen via nasal cannula and that pulse oximetry should have been checked prior to administering oxygen. The LVN admitted to not remembering or recording the resident's pulse oximeter reading at the beginning of the shift. When checked, the resident's oxygen saturation was 85 percent on room air, which increased to 95 percent after oxygen was administered as ordered. A review of the resident's electronic health record and medication administration history showed no documentation that pulse oximetry was checked or that supplemental oxygen was administered as needed on the day in question. The facility's policies required monitoring of pulse oximetry and administration of oxygen therapy when indicated, but these were not followed. The DON confirmed that the resident should have had pulse oximetry checked at the beginning of the shift and received supplemental oxygen as ordered.