Failure to Follow Physician Orders for Pulse Oximetry Monitoring
Penalty
Summary
The facility failed to follow physician orders for twice-daily pulse oximetry checks for two residents with significant medical conditions. One resident, with diagnoses including polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, right below the knee amputation, and obstructive sleep apnea, had a physician order for oxygen saturation monitoring twice daily. However, review of the electronic medical record showed that oxygen saturations were not performed twice daily as ordered on 17 occasions within the first 25 days of June, and there were also days with no documentation at all. The resident's care plan did not include oxygen saturation monitoring as a problem or intervention. Another resident, with a history of fibromyalgia, diabetes, chronic obstructive pulmonary disease, asthma, pulmonary hypertension, and congestive heart failure, also had a physician order to monitor oxygen saturations every shift and as needed. Review of documentation for the first 25 days of June revealed that only one day had twice-daily readings, and on 12 days there were no oxygen saturation levels recorded. Interviews with CNAs and an LPN confirmed that CNAs obtain pulse oximetry readings with vital signs, record them on paper, and provide them to the nurse for entry into the EMR, but the process did not ensure compliance with the physician's orders. The facility's policy required documentation of the date and time of the procedure, and reasons for refusal if applicable, but this was not consistently followed.