Failure to Provide Appropriate Respiratory Care and Follow Oxygen Orders
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with a history of chronic respiratory disease. The resident, who had diagnoses including centrilobular emphysema, vascular dementia, atrial fibrillation, and a documented history of COPD, was admitted with ongoing respiratory needs. Despite physician orders specifying oxygen titration up to 6 liters by nasal cannula to maintain oxygen saturation at 90% or greater, documentation showed the resident received oxygen at higher flow rates (8-10 liters/minute) and had persistently low oxygen saturations (as low as 67%). The facility's staff confirmed that the physician's orders were not consistently followed during this period. Additionally, the resident's plan of care did not reflect the use of oxygen therapy or include interventions, goals, or care planning related to respiratory disease, and COPD was not listed among the resident's active diagnoses despite multiple medical records and hospital notes indicating its presence. The Director of Nursing acknowledged these omissions and confirmed that the facility lacked policies related to the administration of oxygen or physician orders, contributing to the failure to provide appropriate respiratory care.