Failure to Consistently Administer Oxygen per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident requiring continuous supplemental oxygen received care consistent with physician's orders and professional standards of practice. The resident, a 65-year-old with chronic respiratory failure, COPD, severe cognitive impairment, and other significant medical conditions, had a physician's order for continuous oxygen via nasal cannula at 2 to 4 liters per minute. Observations revealed that the resident was found without her nasal cannula in place and with an empty portable oxygen tank on more than one occasion. Staff interviews confirmed that the resident was dependent on staff for care and did not resist or decline oxygen use. Staff acknowledged that monitoring of portable oxygen tanks was inconsistent, with tanks sometimes running empty without being noticed. The facility's policy required nurses to monitor oxygen administration and document the resident's response, as well as to verify and follow physician's orders. Despite this, the resident was left without oxygen for periods of time, and staff did not consistently ensure the resident's oxygen was administered as prescribed.