Failure to Administer Oxygen as Prescribed and Post Required Oxygen Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not administering supplemental oxygen as prescribed by the physician and by failing to post required cautionary signage indicating oxygen use. For one resident with chronic obstructive pulmonary disease, although the care plan and physician orders specified oxygen at three liters per minute via nasal cannula, there was no 'No Smoking - Oxygen in Use' signage posted outside the resident's door. Multiple staff interviews confirmed that both nursing and respiratory therapy staff were responsible for ensuring signage was in place, but the signage was missing and not checked during rounds. Another resident with acute respiratory failure, severe persistent asthma, and hypoxemia had a physician order for oxygen at three liters per minute to maintain oxygen saturation above 90%. However, the resident was observed receiving oxygen at four liters per minute, and the medication aide on duty documented this higher setting but was unable to adjust the concentrator. The resident was capable of changing the setting independently. Staff interviews revealed that nursing staff were expected to check and set the oxygen concentrator according to physician orders every shift, but this was not consistently done. A third resident with COPD, altered mental status, and heart failure had a physician order for oxygen at two liters per minute via nasal cannula for hypoxia. Observations showed the resident receiving oxygen at six liters per minute, while the medication administration record indicated two liters per minute was documented. Nursing staff admitted they did not check the oxygen concentrator settings during their shifts, despite expectations from the DON and administration that these checks should occur every shift.