Failure to Provide Necessary Respiratory Care and Documentation
Penalty
Summary
A resident with diagnoses including malignant neoplasm of the bladder, secondary neoplasm of the bone, toxic encephalopathy, and osteoporosis with pathological fractures was observed to have an oxygen concentrator at the bedside. The resident had moderate cognitive impairment and an activated Power of Attorney for Health Care. Despite requiring supplemental oxygen following a change in respiratory status, there was no physician order for oxygen therapy or a care plan addressing oxygen use in the resident's medical record at the time of the survey. Staff interviews confirmed uncertainty regarding the resident's oxygen use, and the CNA care plan did not include oxygen therapy. The Director of Nursing provided an undated oxygen policy focused on safety and fire prevention but confirmed the absence of a comprehensive oxygen therapy policy. During the survey, the DON located an order from the hospice provider for oxygen therapy, but it was only entered into the medical record during the survey process. Additionally, a standing order for emergency oxygen was also entered into the record during the survey. Prior to these entries, the resident's need for oxygen was not supported by a current order or care plan, and staff were not consistently aware of the resident's oxygen requirements.