Failure to Provide and Monitor Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents, as evidenced by improper monitoring and lack of physician orders for supplemental oxygen use. One resident with vascular dementia and dependence on supplemental oxygen was observed receiving oxygen via nasal cannula, but medical record review revealed that required oxygen saturation levels were not consistently documented during both day and night shifts. The care plan for this resident specified the need for oxygen saturation checks, but these were not performed as ordered. Another resident with non-Alzheimer's dementia, Parkinson's disease, heart failure, and hypertension was observed receiving humidified oxygen through a nasal cannula. However, there were no provider orders in the medical record authorizing the use of oxygen therapy for this resident, despite the care plan indicating that supplemental oxygen should be administered as ordered. The medical director and DON confirmed the absence of an order for oxygen therapy and acknowledged that oxygen saturations should be monitored for residents on supplemental oxygen. A third resident, who had chronic obstructive pulmonary disease and had passed away prior to the survey, was documented as using continuous oxygen at night, but there were no provider orders for oxygen therapy or monitoring in the medical record. Nursing assessments noted the use of oxygen and recorded oxygen saturation levels, but only one oxygen saturation was documented over a period of nearly two months. The DON confirmed that orders for oxygen therapy should have been in place and that monitoring was insufficient. Facility policy and standard nursing procedures require a provider's order for oxygen therapy and regular monitoring of oxygen saturation, which were not followed in these cases.