Failure to Document and Order Oxygen Therapy for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident's medical record included an ongoing assessment of respiratory status, a practitioner's order, and clear indications for the use of oxygen therapy. The resident, who had a diagnosis of COPD, dementia, diabetes type 2, HTN, and hypothyroidism, was observed to have an oxygen concentrator in her room and had documented use of oxygen via nasal cannula on several occasions. However, there was no physician's order for oxygen therapy in the resident's chart, and the care plan did not address oxygen therapy. Oxygen saturation levels were recorded on multiple dates, indicating use of oxygen, but without corresponding orders or documentation of assessment specific to oxygen therapy. Interviews with facility staff, including the MDS-LVN, LVN, CNA, DON, and ADM, confirmed that oxygen therapy requires a physician's order and should be reflected in the care plan. Staff acknowledged awareness of the resident's use of oxygen upon admission but confirmed the absence of a current order and care plan documentation. The facility's policy also requires a physician's order and ongoing assessment for oxygen administration, which was not followed in this case.