Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and treatment for a resident with chronic respiratory failure and other significant diagnoses, including Huntington's disease, dementia, and a history of seizures. The physician's order specified that oxygen should be administered at 2-3 liters per minute via nasal cannula or face mask if the resident's oxygen saturation fell below 92%. On one occasion, the resident was observed in his room receiving oxygen at the prescribed rate. However, on another occasion, the resident was found in the activity room without oxygen, appeared restless, and had an oxygen saturation of 80%. No portable oxygen tank was available at that time. When the low oxygen saturation was identified, an LVN confirmed that the resident should have been on oxygen per the physician's order and returned the resident to his room to administer oxygen. The DON also acknowledged that the resident should have been on oxygen in the activity room to maintain the required oxygen saturation. The facility's policy on oxygen therapy requires that oxygen be administered as ordered by the physician and that residents be monitored for signs of oxygen deprivation, but these procedures were not followed in this instance.