Failure to Administer Oxygen Therapy as Ordered and Maintain Equipment Protocols
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for two residents who were receiving oxygen therapy. For one resident with diagnoses including epilepsy, acute respiratory distress, and pneumonia, the physician's order specified oxygen at two liters per minute (LPM) via nasal cannula (NC) only if oxygen saturation fell below 90%, with instructions to call the physician immediately after placement. However, the resident was observed receiving oxygen at four LPM continuously, despite no documentation of oxygen saturations below 90% or respiratory distress, and staff confirmed there were no changes in orders or status to justify this deviation. For another resident with shortness of breath and asthma, the physician's order was for oxygen at two LPM via NC as needed for oxygen saturation below 90%, with a requirement to call the physician after placement. This resident was observed receiving continuous oxygen, and staff confirmed that the order was for as-needed use, not continuous administration. Additionally, there was no care plan addressing oxygen use for this resident, and documentation did not specify whether pulse oximeter readings were taken on room air or while on oxygen. Staff also failed to document the administration of oxygen as required by the as-needed order. Further deficiencies were observed in the maintenance and safety protocols for oxygen therapy. The oxygen concentrator for the second resident was missing a required filter, which should have been cleaned or replaced weekly according to physician orders. There was also no 'oxygen in use' signage on the resident's doorway, as required by facility policy. Staff interviews confirmed these lapses in following physician orders and facility protocols for oxygen administration and equipment maintenance.