Failure to Document and Notify Physician for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents who required oxygen therapy. For one resident with Alzheimer's disease and dementia, the physician's order specified to start oxygen as needed to maintain oxygen saturation above 90% and to notify the physician upon implementation. The resident's medical record showed multiple instances where oxygen was administered, but there was no documentation in the nursing progress notes indicating that oxygen therapy had been started or that the physician had been notified as required by the order. Similarly, another resident with a left femur fracture and orthopedic aftercare had a physician's order for oxygen therapy under similar conditions. The medical record documented the use of oxygen, but there was no corresponding documentation in the nursing progress notes regarding the initiation of oxygen therapy or physician notification during the relevant period. The Director of Nursing later stated that the SpO2 documentation in both residents' records were documentation errors and should not have been made.