Failure to Obtain Physician Orders and Post Oxygen Signage for Residents on Supplemental Oxygen
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required continuous supplemental oxygen. For both residents, there was no evidence of a physician's order for the administration of oxygen, despite both being observed on continuous oxygen therapy via nasal cannula. One resident, a female with diagnoses including pneumonia, chronic pulmonary disease, and emphysema, was admitted for therapy and was cognitively intact. She was observed using oxygen at 4LPM, but her records lacked both a physician's order and a comprehensive or baseline care plan. The other resident, a male with diagnoses including secondary malignant neoplasm of bone, hypertension, unspecified dementia, and chronic pain, was also observed on oxygen at 5LPM without a physician's order or care plan documentation for oxygen use. Additionally, the facility failed to post required 'oxygen in use' signage for one of the residents receiving oxygen therapy. Observations confirmed the absence of this signage on two separate occasions. The facility's own policy requires verification of a physician's order and the posting of 'oxygen in use' signs as part of safe oxygen administration. The DON acknowledged that orders and signage should have been in place and was unable to explain how the oversight occurred.