Failure to Monitor and Document Oxygen Saturation per Physician Orders
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with physician's orders for one resident. The resident had a history of chronic obstructive pulmonary disease, chronic respiratory failure, and sleep apnea, and had a physician's order for continuous oxygen via nasal cannula at 2-3 liters per minute, with a goal oxygen saturation of 88-92%. Facility policy required staff to check the physician's order for oxygen flow and to document care provided according to the resident's needs. Review of the resident's clinical record showed that there was no evidence that oxygen saturation levels were routinely obtained or documented to ensure the resident was within the prescribed oxygen saturation range. During an interview, the DON confirmed that the clinical record lacked documentation of oxygen saturation percentages and acknowledged that monitoring was necessary to ensure compliance with the physician's orders.