Failure to Implement and Document Oxygen Weaning and CPAP Orders
Penalty
Summary
Facility staff failed to implement hospital discharge treatment plans for a resident requiring supplemental oxygen weaning and CPAP use upon admission. The resident, who had diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, was admitted with specific hospital instructions to continue weaning off oxygen and to use CPAP at night. However, the admission physician orders only included oxygen therapy at 2 liters per minute via nasal cannula, with no orders for oxygen weaning or CPAP use as directed by the hospital discharge plan. The baseline care plan documented oxygen therapy but did not address oxygen weaning or CPAP use. Although a physician order to wean off oxygen was written later, it did not specify a target SpO2 level, and there was no clear documentation of how or if the weaning was being carried out. The comprehensive care plan was updated to include altered respiratory status and CPAP use, but still lacked details on oxygen therapy, weaning protocols, goals, or responsible staff. Nursing staff continued to sign off on oxygen therapy and weaning orders every shift, but there was no evidence they were involved in or aware of the weaning process, and documentation of the resident's response to weaning was absent. Rehab staff reported conducting oxygen weaning trials during therapy sessions and documenting these in the rehab record, but these efforts were not coordinated with nursing staff, who were responsible for ongoing care outside of therapy hours. The facility's policy for oxygen administration did not include a protocol for oxygen weaning or designate responsible staff. Interviews with the DON and other staff revealed a lack of clarity and communication regarding the implementation and documentation of the oxygen weaning process, and the DON was unable to provide further information before the survey concluded.