Failure to Provide and Monitor Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that continuous oxygen therapy was consistently provided and monitored as ordered for a resident with diagnoses including COPD, CHF, and shortness of breath. The physician's order required continuous oxygen at 3 liters per minute via nasal cannula to maintain SpO₂ above 90%, along with regular oxygen saturation monitoring and equipment maintenance. Despite these orders, the resident was repeatedly observed without oxygen in place while in bed, in the room, and while ambulating in the facility. The resident reported not having a portable oxygen tank and stated that oxygen was not used when moving around the building or attending therapy sessions. Staff interviews confirmed that portable oxygen tanks were available but not consistently provided to the resident for use during transport or movement within the facility. Documentation showed that oxygen saturation levels were sometimes recorded while the resident was not receiving oxygen therapy, and staff were unclear about the resident's oxygen requirements, with one physical therapy assistant stating the resident used oxygen 'as needed.' Facility policy required the use of portable tanks when residents on continuous oxygen needed to move away from their concentrator, but this was not consistently implemented.