Failure to Ensure Proper Orders and Documentation for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care consistent with professional standards for four residents who required oxygen therapy. For one male resident with metabolic encephalopathy, oxygen was administered via nasal cannula at 2 liters per minute, but there was no physician's order for oxygen in his chart. The resident reported using oxygen continuously due to shortness of breath, and both the charge nurse and ADON were unaware of the missing order until notified by the surveyor. The ADON stated that orders were entered based on hospital discharge paperwork, and if oxygen was not listed, it was not entered. The administrator confirmed that nursing management was responsible for ensuring orders were documented and placed in the electronic medical record. Another female resident with dementia, shortness of breath, diabetes, and hypertension had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during observation, she was found in bed without oxygen, and there was no oxygen concentrator in her room. The resident was unable to confirm if she used oxygen, and her MDS assessment did not indicate oxygen use during the look-back period, despite the care plan requiring it. A third female resident with a history of UTI, stroke, diabetes, and hypertension was observed receiving oxygen at 3 liters per minute via nasal cannula, but there was no physician's order for oxygen until after surveyor intervention. Additionally, there was no oxygen sign on her door as required by facility policy. A fourth female resident with apraxia, shortness of breath, hypertension, dementia, and depression was also found to be using oxygen without a corresponding physician's order in the record until after surveyor intervention. Staff interviews revealed a lack of awareness regarding the need for written orders and proper documentation for oxygen therapy, and the facility's policy required verification of a physician's order prior to administration.