Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypoxia, pneumonia, cognitive impairment, and dependence on oxygen therapy was not provided oxygen as ordered. The resident's medical orders specified oxygen at 2-4 liters per nasal cannula every shift, and the care plan included interventions to provide oxygen as ordered. Observations revealed that the resident was not wearing her oxygen tubing on two separate occasions, with the tubing found lying across her bed and not in use while she was eating lunch. Interviews confirmed that the resident only wore her oxygen tubing at night, and staff acknowledged that the oxygen tubing was not in place as ordered. Further interviews with the ADON and DON confirmed the lack of adherence to the oxygen order, with the DON updating the care plan to note the resident's tendency to remove the tubing. The facility's policy required care plans to reflect oxygen use and proper storage of cannulas when not in use. The failure to ensure the resident received oxygen therapy as ordered was identified through observations, interviews, and record reviews.