Failure to Provide and Document Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents requiring supplemental oxygen. For one resident with diagnoses including paraplegia, morbid obesity, obstructive sleep apnea, and COPD, there was a physician's order for continuous oxygen via nasal cannula to maintain oxygen saturation at or above 92%. Despite this order, the resident was repeatedly observed without the nasal cannula in place and breathing room air. Documentation in the Medication Administration Record (MAR) was frequently left blank, indicating that oxygen administration or refusal was not recorded as required. Interviews with staff confirmed that the resident often refused oxygen, but these refusals were not documented, and the physician was not notified to clarify or update the order, as required by facility policy. The same resident's medical records showed multiple instances over several weeks where there was no evidence of oxygen being administered or refused, and no documentation of physician notification. The Director of Nursing acknowledged that the facility's policy was not followed, as refusals and non-compliance with the physician's order were not documented, and the physician was not informed. The facility's policy requires that refusals of treatment be documented in detail and that the physician be notified in a timely manner, especially when the resident is non-compliant with prescribed treatments. For a second resident with encephalopathy and acute respiratory failure with hypoxia, there was a physician's order for oxygen via nasal cannula to maintain oxygen saturation at or above 92%. During observation, the resident's oxygen tubing was found off and not attached, and staff were unable to determine how long the resident had been without oxygen. The Director of Nursing stated that staff should be rounding every hour to ensure medical equipment is properly in place and that oxygen should be administered as ordered. The facility's policy on oxygen therapy requires that oxygen be administered per physician orders and that staff ensure safe and appropriate use of medical devices.