Deficient Oxygen Therapy Administration and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in the administration and monitoring of oxygen therapy. One resident with chronic obstructive lung disease and respiratory failure was observed receiving oxygen at a flow rate of 5 liters per minute (LPM) on several occasions, despite a physician's order specifying 3 LPM. Nursing staff documented that the flow rate was checked, but interviews revealed that the checks may not have been performed as required, and the incorrect flow rate was not identified or corrected until observed by surveyors. Another resident with COPD, heart failure, and asthma was found to be using oxygen at 2 LPM via nasal cannula without a current physician's order. The resident and nursing staff confirmed that oxygen was used regularly, but a review of the medical record showed that the order for oxygen had expired and was not renewed after recent hospitalizations. The lack of a current order was acknowledged by both nursing staff and the physician assistant, who stated that an order should have been present for ongoing oxygen use. Additionally, two residents receiving continuous oxygen therapy did not have required signage posted outside their rooms to indicate oxygen use. Observations confirmed the absence of signage, and both nursing staff and administration acknowledged that the signage should have been in place. These deficiencies were identified through record reviews, direct observations, and staff interviews, affecting four of six residents reviewed for respiratory care.