Failure to Ensure Safe and Documented Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including psychotic disorder, dementia, COPD, and hypertension, observations showed she was using oxygen at four liters via nasal cannula, despite a physician's order for three liters continuously. The resident was seen adjusting her own oxygen levels, and this change was not documented. Additionally, the Medication Administration Records (MAR) from January through May did not show that oxygen therapy was signed out, and care plans indicated the need to monitor and administer oxygen as ordered. For another resident with diagnoses such as diabetes, asthma, dementia, and depression, observations revealed she was on three liters of oxygen via nasal cannula, with a physician's order to administer oxygen at three liters as needed and to titrate up to four liters to maintain oxygen saturation above 90%. The MAR indicated PRN oxygen was signed out, but there was no documentation of the flow rate as required by the titration order. The care plan required monitoring and use of oxygen as ordered, but the lack of documentation and adherence to the prescribed flow rates contributed to the deficiency.