Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Monitoring
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 heart failure and chronic pulmonary edema, there were multiple incidents where the resident's portable oxygen tank was found empty, both in the morning and at dinner time, resulting in low oxygen saturation levels. Documentation did not show that a respiratory assessment was completed after the resident was found without oxygen, and there was a lack of consistent monitoring and documentation of oxygen saturation. The resident experienced episodes of respiratory distress and was ultimately sent to the hospital after her oxygen saturation dropped significantly despite interventions. Another resident with heart failure and atrial fibrillation was observed receiving continuous oxygen therapy via nasal cannula, although the physician's order specified oxygen as needed for shortness of breath to maintain saturation above 90%. The medication administration record did not indicate that oxygen had been administered as needed, and the last documented oxygen saturation was several days prior, showing the resident was on room air. There was no ongoing documentation of oxygen saturation monitoring as required by the physician's order and facility policy. Facility policy required that oxygen be administered per physician order, with initial and ongoing assessment and documentation of the resident's condition and response to therapy. The policy also required staff to check portable oxygen tanks for sufficient supply and to regularly monitor tanks while in use. These requirements were not consistently met, as evidenced by the lack of respiratory assessments, insufficient monitoring of oxygen saturation, and failure to ensure oxygen tanks were adequately filled for residents requiring oxygen therapy.