Failure to Consistently Provide and Document Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to consistently provide and document respiratory care for a resident with multiple respiratory diagnoses, including lung cancer, COPD, emphysema, and respiratory failure. The resident was cognitively intact and had a physician's order for oxygen at 8 LPM via nasal cannula, with instructions to remove for ADLs. The care plan and electronic medication administration record reflected this order. However, observations revealed the oxygen concentrator was set at varying levels (3, 5, and 6 LPM) rather than the prescribed 8 LPM, and staff reported following hospice guidance to titrate oxygen down, though no corresponding order was found in the clinical record at the time of survey. Documentation in the resident's clinical record was inconsistent, with oxygen flow rates and usage not always recorded, and gaps in data for several weeks. Hospice notes indicated attempts to decrease oxygen, but the official order to titrate oxygen was not entered into the facility's record until after the surveyor's inquiry. Staff interviews revealed confusion about the current orders, with reliance on verbal or faxed instructions from hospice that were not properly documented. This lack of consistent documentation and adherence to physician and hospice orders led to the identified deficiency.