Failure to Provide Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a history of diabetes mellitus, hypertension, and heart failure with preserved ejection fraction. The resident was admitted with recommendations from medical providers for supplemental oxygen to maintain oxygen saturation above ninety-two percent. However, the care plan did not address oxygen use or respiratory needs, and there was no evidence of an order for oxygen therapy. Multiple documented oxygen saturation readings were at or below ninety-two percent, with some as low as eighty percent, all recorded while the resident was on room air. There was no documentation that staff re-checked oxygen saturation after low readings, applied oxygen, or notified the provider of these findings. Interviews with staff and review of facility policies confirmed that staff were expected to notify providers and obtain orders in the event of low oxygen saturation or respiratory distress. Despite this, there was no evidence that the provider was contacted or that oxygen was administered as a nursing or emergency measure. The resident's family also reported observing episodes of respiratory distress and felt that staff did not respond appropriately. Facility policies required communication of changes in condition and administration of oxygen as ordered or as an emergency measure, but these procedures were not followed in this case.