Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with cerebral palsy and acute respiratory failure was observed sleeping in bed with a nasal cannula in place, but the oxygen concentrator was set at 0 liters per minute, despite a physician's order and care plan specifying oxygen at 2 liters per minute via nasal cannula while in bed. Both a registered nurse and the chief nursing officer confirmed that the oxygen concentrator should have been set to 2 liters per minute but was not. Another resident with chronic heart failure and chronic respiratory failure with hypercapnia was observed sleeping in bed with an oxygen cannula in place, but the oxygen tubing was not connected to the oxygen concentrator. The physician's order required oxygen at 4 liters per minute via nasal cannula, and the care plan documented oxygen therapy as ordered. A registered nurse stated that the CNAs had put the resident to bed and must have forgotten to connect the tubing, and the charge nurse confirmed that the CNAs should have ensured the cannula was connected after moving the resident.