Failure to Monitor and Care Plan Oxygen Therapy for Resident with Respiratory Illness
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a history of severe cognitive impairment, pneumonia, COPD with acute exacerbation, and other significant medical conditions. The resident had a physician order for oxygen therapy to maintain SpO2 above 90%, but multiple documented oxygen saturation readings fell below this threshold. Despite these low readings, there was inconsistent follow-up to recheck oxygen saturation levels to ensure they returned to or remained within the prescribed parameters. Documentation revealed that the resident frequently removed her nasal cannula, resulting in further drops in oxygen saturation. Staff notes indicated that the resident required frequent redirection to keep the oxygen in place, and her oxygen levels varied significantly, sometimes remaining below the ordered threshold for extended periods. Progress notes also described diminished lung sounds and episodes of shortness of breath, but there was a lack of consistent, timely reassessment of oxygen saturation after low readings. Additionally, review of the resident's care plan and baseline care plan showed that they did not include goals or interventions related to her oxygen therapy needs, despite her ongoing use of supplemental oxygen and her tendency to remove the device. The facility's policies provided no clear guidance on managing oxygen saturation levels or responding to out-of-range readings, contributing to the deficiency in respiratory care for this resident.