Failure to Document and Assess Supplemental Oxygen Use
Penalty
Summary
The facility failed to ensure continuous supplemental oxygen was provided as needed for a resident with a physician's order for oxygen at 1-5 liters per minute via nasal cannula, to be administered when oxygen saturation (SpO2) was less than 88%. Review of the resident's medical record showed no documentation of oxygen flow rate in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), despite multiple observations of the resident using 4L of oxygen via nasal cannula on several occasions. The resident's SpO2 levels for the month were consistently within normal range (92% to 98%), and daily skilled charting summaries documented normal breath sounds and respiratory rates with no respiratory distress. Interviews with facility staff revealed a lack of clarity regarding the assessment and documentation of the resident's need for continuous versus PRN oxygen. The Resident Care Manager and LPN acknowledged that nurses should monitor the resident's SpO2 on room air to determine the need for supplemental oxygen, but there was no evidence this was being done or documented. The Director of Nursing Services stated that nurses were expected to assess and document the need for continuous oxygen and record PRN oxygen use in the MAR/TAR, which was not observed in the records reviewed.