Failure to Provide and Document Ordered Oxygen Therapy and Proper Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards and physician orders for two residents. One resident with COPD, hypertension, and anemia was observed multiple times with an oxygen concentrator set at levels inconsistent with the physician's order of 2 liters per minute via nasal cannula. Documentation in the Medication Administration Record was incomplete, with several shifts lacking evidence that the ordered oxygen therapy was provided. The resident's care plan required oxygen administration as ordered, but observations and staff interviews confirmed the prescribed settings were not consistently followed. Another resident receiving oxygen therapy was also observed with the concentrator set below the ordered 2 liters per minute on several occasions. The Treatment Administration Record showed multiple shifts where monitoring of oxygen therapy was not documented as required. The care plan for this resident included interventions to provide oxygen as ordered, but staff interviews and record reviews confirmed that these interventions were not consistently implemented. Additionally, the facility failed to ensure proper storage of respiratory equipment for two other residents. Nebulizer masks were observed left unbagged on bedside tables after use, contrary to facility policy requiring such equipment to be bagged when not in use. Staff interviews confirmed awareness of the policy, and facility procedures outlined the need for proper cleaning and storage of respiratory equipment, which was not followed in these instances.