Failure to Provide and Document Physician-Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with physician orders and professional standards for a resident with multiple respiratory diagnoses, including COPD and pulmonary embolism. The resident was observed receiving continuous oxygen at a flow rate of 4.5 liters per minute (LPM), which exceeded the physician's order of 2 LPM as needed. Both a CNA and an LVN confirmed that the resident had been on continuous oxygen at this higher rate, and the LVN acknowledged that this did not align with the physician's order. The DON and RN also confirmed that the administration of oxygen at this rate and frequency was not appropriate for the resident's condition and could lead to adverse outcomes. Additionally, the resident was observed on the facility patio without supplemental oxygen, exhibiting increased respiratory rate and signs of respiratory distress. The CNA responsible for the resident stated that the resident refused oxygen and was taken outside without notifying the LVN. The LVN was not aware of the resident's refusal or removal of oxygen until after the fact, and upon assessment, found the resident's oxygen saturation to be below normal. The DON stated that the expectation was for the CNA to immediately notify the LVN of the refusal so that appropriate monitoring and interventions could be implemented. Documentation of the resident's oxygen flow rate was also lacking, as there was no record of the amount of oxygen administered from 4/29/2025 to 5/20/2025. The LVN admitted to forgetting to check and document the flow rate, and the DON confirmed that documentation of oxygen administration was expected each shift. The facility's policy required proper flow of oxygen, documentation of the rate, and notification of supervisors in the event of refusal, none of which were consistently followed in this case.