Failure to Provide and Document Appropriate Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by physicians and did not ensure that physician orders and resident care plans included necessary interventions for oxygen therapy. For several residents, physician orders for oxygen therapy were incomplete, lacking essential details such as frequency of use, indications for use, baseline SpO2 levels, and clear instructions on when to initiate or discontinue oxygen. For example, two residents had orders for oxygen titration to maintain saturations above 90%, but the orders did not specify how often oxygen should be administered. Another resident's order and care plan did not document when to start or stop oxygen therapy, and the DON acknowledged that the order was too generic and should have included more specific instructions. Additionally, the facility did not document nursing interventions when a resident's oxygen saturation dropped below the prescribed threshold. In one case, a resident's oxygen saturation was recorded as low as 67% and 82% on different occasions, but there was no documentation of any nursing response or intervention to address these low levels, despite the care plan indicating oxygen should be administered per physician orders. The DON confirmed that staff should have addressed these low oxygen saturations but had not done so. The facility also failed to follow its own policy regarding the maintenance of oxygen equipment. For one resident, oxygen tubing and humidifier were not dated as required by facility policy, and the resident was unaware of when the equipment was last changed. The ADON confirmed that the tubing and humidifier should have been dated and were not, indicating a lapse in adherence to established protocols for respiratory care equipment.