Failure to Follow Oxygen Weaning Orders and Document Care
Penalty
Summary
The facility failed to follow provider orders to wean supplemental oxygen for a resident with severe cognitive impairment, chronic respiratory failure, and dementia. The resident had been hospitalized for sepsis, pneumonia, and urinary tract infection, and was discharged with instructions to be weaned off supplemental oxygen as able, maintaining oxygen saturation at or above 90%. Provider orders and the care plan directed staff to wean oxygen as tolerated, but documentation in the treatment administration record, oxygen saturation summary, and nursing progress notes lacked evidence of any attempts to wean the resident from oxygen or to record oxygen flow rates during such attempts. Observations confirmed the resident was continuously on oxygen via nasal cannula, and interviews with nursing staff and the DON revealed that no recent weaning attempts had been made or documented. The DON verified that the order to wean oxygen was still active and acknowledged the lack of documentation regarding weaning efforts. The facility was unable to provide a policy for resident oxygen use when requested.