Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, heart failure, and respiratory failure. The resident was ordered to receive continuous oxygen at 4 liters per minute, but observations over multiple days showed the oxygen was consistently set at 2 liters, both in the dining room and in bed. Review of the electronic health record and medication administration records revealed discrepancies, with documentation often indicating the oxygen was set at 4 liters, while other records and direct observation showed it was set at 2 or 3 liters. There was no documentation supporting any physician-approved change in the oxygen setting from 4 liters to lower amounts during the review period. Staff interviews revealed confusion regarding the correct oxygen order, with a Certified Medication Aide stating the order was for 2 liters and a Registered Nurse confirming the order was actually for 4 liters. The Assistant Director of Nursing acknowledged the correct order was 4 liters and suggested staff may have missed the order. The Director of Nursing confirmed there was no facility policy related to oxygen therapy, stating that staff follow physician orders and standards of practice.