Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with physician orders for continuous oxygen therapy. Both residents had orders specifying oxygen at 2 liters per minute (LPM) via nasal cannula, with the option to titrate up to 5 LPM to maintain oxygen saturation above 90%. Documentation in the Medication Administration Record (MAR) required staff to record oxygen administration and saturation levels every shift. Despite these orders and documentation requirements, observations revealed that both residents were not consistently receiving oxygen as prescribed. For the first resident, who had diagnoses including COPD and multiple rib fractures, care plans and provider orders indicated the need for continuous oxygen therapy. However, on multiple occasions, the resident was observed without a nasal cannula and not receiving oxygen, even though oxygen saturations were being recorded. On another occasion, the resident was found receiving 5 LPM of oxygen when the order specified 2 LPM unless saturations dropped below 90%. The RN and DON confirmed that the resident should have been on 2 LPM based on current oxygen saturation levels and could not explain the deviation from the order. The second resident, with diagnoses including acute kidney failure and diabetes, also had an order for continuous oxygen therapy. Observations on two separate days found the resident without a nasal cannula and not receiving oxygen. The resident reported only using oxygen at night for sleep apnea, despite the order for continuous use. Both the RN and DON confirmed that the resident should have been receiving oxygen at all times per the provider's order. Facility policies required accurate implementation of provider orders and administration of oxygen therapy by licensed nurses, but these were not followed for either resident.