Failure to Consistently Monitor and Document Oxygen Saturations as Ordered
Penalty
Summary
The facility failed to ensure that oxygen (O2) saturations were obtained and documented as ordered for two residents requiring respiratory care. One resident with chronic kidney disease and hypertension was observed receiving 4 liters of oxygen via cannula, but the medication administration records (MAR) for April and May showed inconsistent documentation of O2 saturation levels, despite a physician's order specifying O2 titration to maintain saturations above 90% every shift. The resident was unable to identify who adjusted the oxygen settings. Another resident with chronic ischemic heart disease and peripheral vascular disease was observed with an O2 concentrator set at 5 liters via nasal cannula. The physician's order for this resident required O2 saturation checks every shift, but did not specify the oxygen flow rate. MAR review for this resident also revealed inconsistent documentation of O2 saturations. The Director of Nursing confirmed the inconsistent documentation for both residents and acknowledged the importance of monitoring and titrating oxygen as ordered. Facility policy required monitoring O2 saturation levels as ordered by the physician.