Failure to Document Ordered Respiratory Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care as ordered by the provider for one resident who uses oxygen therapy. The resident had a provider order for oxygen to be administered by nasal cannula at 2 liters per minute every shift, with instructions to maintain peripheral oxygen saturation (SPO2) between 88-93% and to evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds. Upon review of the clinical record, there was no documentation that the resident's respiratory rate, skin color, and breath sounds were evaluated every shift as ordered. This lack of documentation was confirmed by the surveyor with the DON, Administrator, and Clinical Market Advisor, who acknowledged that the required assessments were not recorded.