Failure to Assess and Document Oxygen Saturation for Resident on Supplemental Oxygen
Penalty
Summary
Facility staff failed to properly assess and document a resident's oxygen saturation levels as required by physician orders. The resident, who had a history of chronic obstructive pulmonary disease and respiratory failure, had a physician order for supplemental oxygen to be administered via nasal cannula at 0.5-1 liter per minute to maintain oxygen saturation above 88 percent, as needed. However, review of the medication administration records for two months showed that while the oxygen order was present, there was no documentation of oxygen saturation checks. The care plan also directed staff to maintain oxygen saturation above 88 percent, but this intervention was not consistently monitored or recorded. Staff interviews confirmed that with such an order, oxygen saturation should be checked at least every shift to determine the need for oxygen. Both a registered nurse and the DON acknowledged that the resident's oxygen saturation should have been monitored every shift according to the order, but this was not done. Observations showed the resident had an oxygen concentrator in the room and was not in respiratory distress at the time, but the required assessments to guide oxygen administration were not performed or documented.