Failure to Provide Respiratory Care Services per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with its policy and physician orders for two residents. One resident, with diagnoses including acute and chronic respiratory failure, asthma, and dementia, had a physician order for continuous oxygen at 3 liters per minute (lpm) via nasal cannula. On multiple observations, the resident was found not wearing the nasal cannula, with the oxygen tubing resting on the chest, and the oxygen concentrator set at 2.5 lpm instead of the ordered 3 lpm. Both the DON and an LVN confirmed the incorrect oxygen setting and acknowledged that the resident was not receiving oxygen as ordered. Another resident, diagnosed with COPD, anemia, and dementia, had a physician order for continuous oxygen at 2 lpm via nasal cannula and instructions to notify the physician if oxygen saturation fell below 92%. The resident's oxygen saturation was documented as 91% on three separate occasions, but there was no evidence in the medical record or SBAR documentation that the physician was notified as required. The DON confirmed the lack of documentation and stated that the licensed staff did not call the physician regarding the low oxygen saturation levels. Facility policy on oxygen administration required staff to review physician orders, observe residents to ensure oxygen is being tolerated, and document the rate, route, and assessment data in the medical record. The policy also required reporting relevant information in accordance with professional standards. These requirements were not met for either resident, as evidenced by the lack of proper oxygen administration and failure to notify the physician of low oxygen saturation.