Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for one resident who had diagnoses including lung cancer, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician's order required continuous oxygen administration via nasal cannula, with oxygen saturation to be maintained above 92%. Medical record review showed that the resident's oxygen saturation was recorded at 92% on room air and with nasal cannula on multiple occasions, and at 93% on room air. Despite the order for continuous oxygen, the resident was not consistently maintained on supplemental oxygen as prescribed. On one occasion, the resident's oxygen saturation dropped significantly from 93% to 51% within less than an hour, leading to the resident being transferred to an acute care facility. Interviews with nursing staff confirmed that the resident should have been on continuous oxygen and that the oxygen should have been titrated to maintain the ordered saturation level. The facility's policy required that all physician orders be specific and complete, and that treatments be administered as ordered, but these requirements were not met in this case.