Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident who was admitted to the facility with severe cognitive impairment had physician orders and a care plan in place for continuous oxygen therapy at 2 liters per minute via nasal cannula for dyspnea. Despite these orders, during an observation, the resident was found in bed without oxygen in use; the oxygen concentrator was turned off and the nasal cannula was not applied. Additionally, the oxygen tank attached to the resident's wheelchair was empty. Interviews with facility staff revealed a lack of awareness regarding any changes to the resident's oxygen orders, and upon review, staff confirmed that the order for continuous oxygen therapy remained in effect. Both the LPN and the DON acknowledged that the resident was not receiving oxygen as prescribed at the time of observation, and the DON confirmed that the expectation was for the resident to have oxygen applied at all times per the current orders.