Failure to Ensure Proper Orders and Equipment Changes for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed receiving oxygen therapy without a corresponding physician order or care plan intervention. The resident, who was alert and oriented, reported that the oxygen tubing and nasal cannula had not been changed. Observation confirmed the tubing and cannula were undated, and staff were unable to verify when they were last changed. Review of the resident's medical record and care plan revealed no current orders or interventions for oxygen administration, despite documentation that oxygen was established in the home. Further review of facility records showed that the first documentation of cleaning the oxygen concentrator and changing the tubing occurred several days after the resident's admission. Facility policy required verification of provider orders prior to oxygen administration and mandated weekly changes and documentation of tubing, mask, and cannula. Staff interviews confirmed a lack of knowledge regarding the last change of equipment and the absence of a current order for oxygen, indicating noncompliance with facility policy and standard respiratory care procedures.