Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with the residents' plans of care for three residents with orders for oxygen therapy. For one resident with COPD and diabetes, there was no assessment or documentation of oxygen saturation for a period of several days, despite physician orders to titrate oxygen based on saturation levels. Observations revealed that this resident was receiving four liters of oxygen per minute, contrary to the physician's order of two liters, and there was no 'Oxygen in Use' sign outside the room. The resident also did not have a care plan addressing oxygen administration, and the ADON confirmed that monitoring and documentation of oxygen saturation were not performed as required. Another resident with heart failure and peripheral vascular disease was observed receiving varying amounts of oxygen (one liter and 2.5 liters per minute) instead of the prescribed two liters per minute. There was also no 'Oxygen in Use' sign outside this resident's room, and the resident did not have a care plan for oxygen administration. The DON acknowledged the absence of a care plan and stated that such a plan was necessary to guide staff in providing safe and effective oxygen therapy. A third resident with COPD and sequelae of cerebral infarction was observed receiving more than the prescribed amount of oxygen (three liters and 2.5 liters per minute instead of two liters per minute) and also lacked an 'Oxygen in Use' sign outside the room. Although this resident had a care plan for oxygen therapy, the prescribed oxygen flow was not followed. Staff interviews confirmed the importance of adhering to physician orders for oxygen therapy and the need for appropriate signage to prevent fire hazards, as outlined in the facility's policy and procedure for oxygen administration.