Failure to Follow Physician's Orders for Oxygen Saturation Monitoring
Penalty
Summary
A deficiency was identified when the facility failed to follow a physician's order for a resident with severe cognitive impairment and multiple diagnoses, including severe protein-calorie malnutrition, anorexia, aphasia, and cognitive communication deficit. The physician's order required that the resident's oxygen saturation be checked every shift, and if the saturation was less than 92%, oxygen should be administered at 2 liters per minute via nasal cannula as needed. Review of the resident's medication administration record (MAR) for two consecutive months showed no evidence that these oxygen saturation checks were performed or documented. Interviews with the LPN responsible for the resident and the Director of Nursing confirmed that the required oxygen saturation checks were not documented in the task documentation, nurse's notes, or MAR. Both staff members acknowledged the existence of the physician's order and the lack of evidence that the order was followed, confirming the deficiency in care for the resident.