Failure to Ensure Safe and Ordered Oxygen Administration and Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining physician orders for oxygen administration, not administering oxygen at the prescribed rate, and not posting required cautionary signage. For one resident with a diagnosis of dyspnea, there was no physician order, care plan, or documentation supporting the use of oxygen therapy, yet the resident was observed with an oxygen concentrator in use on multiple occasions. Staff interviews confirmed a lack of awareness regarding the absence of an order, and no communication was found in the medical records or communication logs to justify the ongoing use of oxygen. Another resident, admitted with cardiac and dementia diagnoses, was also found to be using oxygen without a current physician order. Both the resident and her representative stated that oxygen was used primarily at night and during episodes of shortness of breath. Staff interviews revealed that the resident had been using oxygen for several months, but the physician assistant declined to provide a new order without supporting oxygen saturation data, and the DON could not locate a relevant protocol or standing order. A third resident with chronic respiratory failure and congestive heart failure had a physician order for continuous oxygen at 2 liters per minute, but observations showed the oxygen was being administered at 3.5 liters per minute. Additionally, there was no cautionary signage posted to indicate oxygen was in use. Staff interviews confirmed that nurses were responsible for checking oxygen flow rates and posting signage, but these actions were not performed as required. The DON and nurse practitioner both acknowledged the discrepancies in oxygen administration and signage.