Failure to Ensure Safe and Ordered Oxygen Therapy for Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring oxygen therapy was administered according to physician orders and by not obtaining a physician's order for oxygen use. In one instance, a resident with a history of Covid-19, chronic respiratory failure with hypoxia, and asthma was observed wearing a nasal cannula, but the oxygen concentrator was turned off despite a physician's order for oxygen at 3 liters per minute. Staff confirmed the oxygen should have been turned on, and the resident's care plan required oxygen administration per physician's orders. In another case, a resident with diagnoses including malignant neoplasm of the right main bronchus, COPD, and pan lobular emphysema was observed with an oxygen concentrator in the room and evidence of recent oxygen use, but there was no physician's order for oxygen found in either the electronic health record or the hospice binder. Staff and the ADON confirmed the absence of a written order for oxygen use, despite the resident's care plan indicating oxygen should be administered per physician's orders. Facility policies required verification of physician orders and proper documentation for oxygen administration, which was not followed in these cases.