Failure to Assess Need for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Peripheral Vascular Disease was observed to be receiving oxygen therapy via nasal cannula at 2 liters per minute on multiple occasions. The physician's order specified oxygen at 2 liters per nasal cannula as needed every shift, with instructions to notify the physician if oxygen saturation was less than 94% or as needed for shortness of breath. Despite these orders and ongoing administration of oxygen, there was no documented evidence in the clinical record that the resident had been assessed for the need for oxygen therapy. Staff interviews confirmed the resident was on oxygen, and facility policy required documentation of the procedure in the medical record, which was not present.