Failure to Provide and Document Oxygen Therapy per Provider Orders
Penalty
Summary
The facility failed to provide oxygen services according to provider orders for two residents. For one resident with heart failure, COPD, and diabetes, provider orders specified oxygen at 2 liters per minute (L/m) with nursing staff required to verify the flow rate three times daily. However, observations on multiple occasions showed the resident was receiving oxygen at 5 L/m, while nursing documentation inaccurately indicated the resident was receiving oxygen at 2 L/m. Interviews with staff confirmed that the oxygen was not being administered as ordered and that documentation did not reflect the actual flow rate provided. For another resident with respiratory failure, COPD, and asthma, observations showed the resident was receiving oxygen at 2 L/m via nasal cannula, and the resident reported ongoing use of oxygen since hospital readmission. However, a review of provider orders for the relevant period revealed there was no order for oxygen use. Staff interviews confirmed that oxygen administration should be based on provider orders and that documentation for this resident did not meet expectations.