Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
Staff failed to provide oxygen therapy as ordered by the physician for a resident with chronic respiratory failure, respiratory disorder, and cognitive impairment. The resident's care plan directed staff to provide oxygen as ordered, with an initial physician order for continuous oxygen at 5 liters per minute via nasal cannula. A subsequent order instructed staff to wean oxygen therapy for saturation levels over 94% and to administer 1-3 liters per minute as needed to maintain oxygen saturation between 88-93%. During a medication administration observation, the resident was found resting in bed without oxygen in place. An RN administered medications and then checked the resident's oxygen saturation, which was 80% on room air. The RN then applied oxygen via nasal cannula. The RN confirmed that the resident was not wearing oxygen at the time of medication administration and described the weaning process as a gradual reduction of oxygen flow with monitoring, not complete removal without monitoring.