Failure to Provide Physician-Directed Oxygen Therapy and Care Plan Inclusion
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for one resident. Observation showed the resident using a nasal cannula connected to an oxygen concentrator set at 4 liters per minute. However, review of the clinical record revealed there was no physician's order specifying the amount of oxygen to deliver, the method of delivery, or whether the oxygen therapy was to be administered as needed or continuously. The only order present was to check oxygen saturation every shift and apply oxygen to keep saturation above 90% for low readings, but it did not include the necessary details for safe administration. Additionally, the resident's Care Plan did not include a focus area or interventions related to the required oxygen therapy, despite documentation that the resident needed oxygen and had relevant diagnoses such as Guillain-Barre Syndrome, anemia, and obesity. Staff interviews confirmed the expectation that oxygen usage should be reflected in both a physician's order and the Care Plan, but these were not present for the resident in question.