Failure to Ensure Physician's Order and Proper Storage for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen therapy was in place and that oxygen equipment was stored properly for a resident with multiple respiratory and cardiac diagnoses. Observations over several days showed that the resident's oxygen concentrator was set to deliver 3 liters per minute, but the resident was not always wearing the nasal cannula, which was found lying on the floor on multiple occasions. The clinical record review revealed that there was no active physician's order for oxygen therapy until several months after the resident returned from the hospital, despite the resident's ongoing use of oxygen equipment. Additionally, the nasal cannula was not stored in a manner that would prevent contamination when not in use. The care plan noted the resident's non-compliance with physician's orders, including refusal to wear oxygen as ordered. Interviews with facility staff confirmed the absence of a current physician's order for oxygen therapy during the period in question, and facility policies required verification and documentation of such orders, as well as proper storage and administration of oxygen equipment.