Failure to Provide Appropriate Respiratory Care and Oxygen Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for one resident. Review of the facility's policy indicated that only licensed clinicians with demonstrated competence should administer oxygen as ordered by a provider, and in emergencies, a provider's order should be obtained as soon as possible. However, for the resident in question, the need for oxygen was not documented in the resident's orders, baseline care plan, or admission Minimum Data Set (MDS), despite the resident having diagnoses such as diabetes, COPD, obstructive and reflux uropathy, and high blood pressure. Observations showed the resident was using a nasal cannula with oxygen administered on two separate occasions, but there was no evidence of a provider's order or care planning related to oxygen use. Interviews with the DON and NHA confirmed that the facility did not ensure clinician competence in administering oxygen, failed to obtain a provider's order, and did not document the resident's oxygen needs in the care plan or MDS.