Failure to Ensure Proper Orders and Documentation for Oxygen Supply Changes
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage was observed using oxygen therapy without proper documentation or adherence to professional standards for respiratory care. The resident was seen with undated nasal cannulas attached to both an oxygen concentrator and a portable oxygen tank. Multiple staff interviews confirmed that nurses were responsible for changing and dating the nasal cannulas, and that such changes were expected to occur weekly. However, there was no physician's order in the medical record for changing the oxygen supplies, and the cannulas in use were not dated as required. Further review and staff interviews revealed that the process for changing and documenting oxygen supplies was not being followed due to the absence of a physician's order in the resident's medical record. The lack of an order resulted in the failure to consistently change and date the nasal cannulas as per facility protocol and professional standards. This lapse was confirmed by nursing staff and the regional nurse consultant, who acknowledged that the required order was missing and that the changes had not been occurring as expected.