Failure to Monitor Oxygen Saturation per Provider Orders
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with provider orders and professional standards for a resident with moderately impaired cognition and diagnoses including acute respiratory failure with hypoxia and COPD. The resident had a provider order for continuous oxygen at 2 liters per minute by nasal cannula, with instructions to maintain oxygen saturations above 90% and to check oxygen saturation every shift. The care plan also directed staff to administer oxygen according to the provider order. However, review of the electronic health record showed that oxygen saturation was not checked every shift as required, with documentation indicating checks occurred only sporadically over a two-month period. Interviews with the resident, LPN, NP, and DON confirmed that staff were not consistently monitoring oxygen saturation as ordered, and there was no task on the treatment administration record to prompt staff to perform these checks. The facility's policy on oxygen administration required assessment of oxygen saturation when a resident was receiving oxygen therapy, but this was not followed. The lack of consistent monitoring and documentation was acknowledged by staff and leadership during interviews.