Failure to Ensure Ordered and Properly Managed Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care for a resident receiving oxygen therapy by not ensuring required orders, care planning, equipment dating, and signage were in place. During an observation, the resident was found in bed with oxygen tubing connected to a concentrator, but the tubing and water bottle, as well as the nebulizer, were not dated, and there was no oxygen administration sign posted on the door. On a later observation, the same resident was in bed without oxygen in use, and the nebulizer face mask was on the floor with tubing that also lacked a date. Review of the physician orders showed there was no documented order for oxygen, and the clinical record did not contain a care plan addressing oxygen use. In interviews, a hospice provider stated that residents on oxygen should have an order with the facility, and an RN confirmed there should be an oxygen order for anyone utilizing it. The facility’s own oxygen administration policy, provided by the Administrator, requires verification of a physician’s order, review of the resident’s care plan for special needs, and placement of an “Oxygen in Use” sign on the room entrance door, all of which were not followed for this resident.
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