Failure to Obtain and Document Provider Orders for Oxygen Therapy and Dental Services
Penalty
Summary
The facility failed to ensure that provider orders were obtained and maintained for specific resident care interventions, including oxygen therapy and dental services, for three residents. For one resident with diagnoses including dementia, Parkinson's disease, heart failure, and hypertension, observations over several days confirmed the use of 2 liters per minute of humidified oxygen via nasal cannula, both during the day and at night. Despite the care plan referencing supplemental oxygen, there was no provider order for oxygen therapy in the medical record. The Medical Director and DON both confirmed the absence of such an order after reviewing the record. Another resident, who had chronic obstructive pulmonary disease and had since passed away, was documented in multiple nursing assessments as receiving oxygen therapy at various times and amounts. However, the medical record did not contain any provider orders for oxygen therapy or for monitoring oxygen saturation during the period the therapy was administered. The DON acknowledged that only one oxygen saturation was recorded during the relevant timeframe and that orders for oxygen therapy should have been in place. A third resident, admitted with legal blindness and dental issues, reported intermittent dental pain and had requested a dental appointment two months prior. A provider's progress note indicated the need to schedule a follow-up dental appointment for extractions, but no physician order for dental services was found in the medical record. Staff interviews revealed a lack of awareness regarding the resident's request and the absence of any scheduled dental appointments. Facility policies required assistance in making dental appointments and providing dental services, but these were not followed as no order was entered.