Failure to Follow Physician Orders and Document Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and provide safe and appropriate respiratory care for all eight sampled residents requiring oxygen therapy or respiratory support. Surveyors observed that oxygen therapy was not administered as ordered, with several residents either not receiving oxygen when prescribed, or receiving it inconsistently. In multiple cases, oxygen tubing and nebulizer equipment were not dated or changed according to physician orders or facility policy, and documentation in the Minimum Data Set (MDS) assessments was inaccurate or incomplete for residents receiving oxygen therapy. For example, one resident with diagnoses including heart failure and COPD had physician orders for oxygen therapy as needed to maintain oxygen saturation above 93%, but the care plan did not include goals or interventions for oxygen therapy, and the MDS did not reflect oxygen use despite documented administration. Another resident with heart failure and pneumonia was observed receiving oxygen, but the tubing was not dated, and the MDS assessment did not indicate oxygen therapy. Similar issues were found with other residents, including missing or outdated documentation of oxygen and nebulizer tubing changes, lack of care plan interventions, and discrepancies between observed care and physician orders. Additionally, some residents were not provided with the prescribed oxygen therapy at all, as observed in the case of a resident with an order for continuous oxygen who was repeatedly found without oxygen equipment in her room. Staff interviews revealed inconsistent knowledge and practices regarding the frequency of changing and dating respiratory equipment, and MDS coordinators were unable to verify the accuracy of assessments for residents under their care. These findings demonstrate a pattern of noncompliance with physician orders, inadequate documentation, and failure to ensure safe and appropriate respiratory care for residents requiring oxygen therapy.