Failure to Follow Physician Orders and Proper Oxygen Administration Procedures
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to follow physician orders and care plan interventions for a resident requiring oxygen therapy. A female resident with a history of transient ischemic attack and brain aneurysm was observed receiving oxygen via nasal cannula at 5 liters per minute (L/M), despite a physician order and care plan specifying oxygen at 2 L/M to maintain oxygen saturation above 92%. Additionally, the resident's oxygen was administered with an empty humidifier bottle, contrary to facility policy and staff statements that the humidifier should be filled with distilled water to prevent drying of the nares. Staff interviews confirmed the humidifier was empty and that the oxygen flow rate did not match the physician's order.