Failure to Ensure Proper Oxygen Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory care as ordered by the physician. Specifically, the resident had a physician's order for oxygen via nasal cannula at 2 LPM every shift, with instructions to notify the physician if oxygen saturation dropped below 88%. However, observations revealed that the oxygen concentrator was set at 2.5 LPM, not the ordered 2 LPM. Additionally, a CNA applied the nasal cannula to the resident instead of a licensed nurse, contrary to facility policy and staff statements that only licensed nurses should administer oxygen to ensure correct settings. The nasal cannula was also not stored in an oxygen storage bag as required for infection control. Further review showed that the resident's Minimum Data Set (MDS) was not accurately coded to reflect that the resident was on continuous oxygen therapy, despite documentation and staff verification that the resident was receiving oxygen. Oxygen saturation readings were recorded as being taken on room air on multiple occasions, which did not align with the physician's order for continuous oxygen. These findings were confirmed through interviews with the CNA, LVN, and DON, as well as review of the resident's medical record and facility policies.