Failure to Administer Oxygen per Physician Orders and Lack of Required Oxygen Signage
Penalty
Summary
The facility failed to ensure that oxygen was administered according to physician orders and that appropriate signage was present for residents using oxygen. For one resident with a history of malignant neoplasm of the oropharynx and hypotension, who had a tracheostomy and required oxygen, the physician order specified oxygen at 35 percent with a two-liter bleed per trach collar. However, observation revealed the oxygen was set at seven liters, and the trach collar mask was not in use until reapplied by an RN, who was unaware of the correct order and did not adjust the oxygen setting. The RN later confirmed she had not checked the physician order and did not realize the oxygen was set incorrectly. The DON also verified the correct order was for two liters, not seven. Additionally, another resident with COPD had a physician order for two liters of oxygen as needed, with instructions to change tubing and nasal cannula weekly. Observation found an oxygen tank and tubing in the resident's room, but there was no sign on the door indicating oxygen was in use, as required by facility policy. An LPN confirmed the resident used oxygen as needed and that the appropriate signage was missing. The facility policy stated that a "no smoking or oxygen in use" sign should be in place for any resident using oxygen.