Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with chronic respiratory failure. The resident was admitted with a physician's order for continuous oxygen at three liters per minute every shift. On one occasion, a physical therapist assistant entered the resident's room and found the oxygen concentrator was not turned on, resulting in the resident's oxygen saturation dropping to 88 percent. After oxygen was administered, the saturation increased to 93 percent. Staff confirmed that the oxygen concentrator had been off when the resident was found, and the administrator acknowledged that staff were expected to follow physician orders for oxygen use. A public complaint was also received alleging that after the resident was returned to their room, staff did not turn on the oxygen concentrator, and it remained off for several hours until discovered by staff.