Failure to Document and Manage Supplemental Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate documentation and proper management of supplemental oxygen therapy for a resident with chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. Observations revealed that the resident was receiving oxygen via nasal cannula at varying flow rates, but the oxygen tubing was undated on multiple occasions, both in the resident's room and on a portable tank attached to the resident's wheelchair. Additionally, there was no documentation in the electronic medication or treatment administration records of the resident's supplemental oxygen use on the observed dates. The resident's electronic health record also lacked documentation of oxygen saturation (SPO2) measurements without oxygen and did not indicate that the oxygen tubing had been changed as required. Interviews with facility staff confirmed that the physician's order required supplemental oxygen to be administered if the resident's SPO2 was below 90, and that oxygen tubing should be changed weekly with corresponding documentation. Staff were unable to locate documentation of the resident's oxygen use, SPO2 assessments without oxygen, or evidence that the tubing had been changed according to protocol. The Chief Nursing Officer acknowledged that documentation of SPO2 assessment and effectiveness of oxygen therapy was not completed, and that the standard for changing oxygen tubing was not met.