Failure to Provide and Document Appropriate PRN Oxygen Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, heart failure, and hypertension was observed on two occasions receiving continuous oxygen via nasal cannula at a flow rate of 2 liters. The physician's order specified oxygen at 2 liters via nasal cannula as needed (PRN) for shortness of breath, with instructions to maintain oxygen saturation above 90. The resident's care plan also indicated oxygen should be administered as ordered due to the risk of altered oxygen levels from heart failure. Despite these orders, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month lacked documentation that PRN oxygen had been administered or that the resident's oxygen saturation had been monitored. The resident was cognitively impaired and dependent on staff for all activities of daily living. During an interview, the DON stated that staff kept the oxygen on at all times due to the resident's shortness of breath during care activities, and indicated an intention to update the oxygen orders. Facility policy required documentation of oxygen administration details, but this was not found in the records.