Failure to Administer Ordered Oxygen Therapy and Label Equipment
Penalty
Summary
Facility staff failed to administer oxygen therapy as ordered by the physician for one resident. Observations revealed that the resident was not receiving continuous oxygen via nasal cannula at two liters, as prescribed. The oxygen concentrator was present in the resident's room, but the humidifier bottle was found on the floor and there was no oxygen tubing connected to the concentrator. The resident's spouse confirmed that the oxygen had not been in use since the previous day, and that the tubing had been removed from the room. Multiple observations throughout the day confirmed that the resident was not receiving oxygen as ordered, and staff had not checked on the resident's oxygen levels during this period. Further review showed that the oxygen tubing and humidifier bottle were not labeled or dated, as required. The clinical record indicated that the oxygen order had been signed off as administered, despite the resident not receiving it. The care plan also reflected the need for continuous oxygen at two liters via nasal cannula. Facility policy required licensed clinicians to administer oxygen as ordered, but this was not followed in this instance. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.