Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebrovascular disease, hypertension, and COPD was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per nasal cannula to maintain oxygen saturation above 92%. The resident's care plan included interventions for respiratory therapy, assessment for respiratory distress, and administration of oxygen as ordered. Despite these orders, multiple observations on the same day revealed the resident was not receiving oxygen while in the dayroom and dining room, even though an oxygen tank was present in the wheelchair holder. Staff interviews confirmed the deficiency: a CNA was unaware of the resident's oxygen needs, and an LPN verified that the oxygen tank was empty and that the resident was not receiving the ordered continuous oxygen therapy. The DON also confirmed that the resident should have been on continuous oxygen per the physician's order. These findings indicate that the facility failed to ensure the resident received safe and appropriate respiratory care as ordered.