Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with diagnoses including type II diabetes, dementia, and hypertension was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, with instructions to keep oxygen saturation above 90%. Record review showed that the resident's oxygen saturation dropped to 87% on room air and was at 90% when on 2 liters of oxygen, indicating a need for consistent oxygen therapy as ordered. Despite these orders, observations revealed that the resident was not consistently receiving oxygen as prescribed. On one occasion, the resident wore the nasal cannula, but the oxygen concentrator was not turned on. At another time, the resident was seen participating in activities without wearing the oxygen. Interviews with nursing staff and the medical director confirmed that the resident should have been on continuous oxygen per the physician's order, and that the order had not been changed to allow for discontinuation or intermittent use.