Failure to Follow Oxygen Orders and Document Respiratory Distress and Treatment
Penalty
Summary
The facility failed to provide respiratory services in accordance with professional standards of practice for one resident receiving oxygen therapy. During observation, the resident was found in bed on oxygen via nasal cannula with the concentrator set at 4 L/min, while the physician’s order in the medical record specified oxygen at 2 L/min. The humidification water bottle and oxygen tubing in use had no dates indicating when the bottle was opened or when the tubing was applied. The DON confirmed at the bedside that the oxygen was set at 4 L/min and stated she would review the nurse’s actions and the physician’s orders. Further record review showed a respiratory therapy note from the previous day documenting that the resident had been found on a non-rebreather mask, diaphoretic, and breathing fast, but there was no additional documentation in the medical record regarding this episode of respiratory distress or the use of the non-rebreather mask. In interviews, the RT reported being called by an NP to assist with the resident, who was on a non-rebreather, and described using breathing techniques and touch therapy with the NP and ADON to help calm the resident and reduce the respiratory rate. The NP stated she had been called because the resident was having trouble breathing with low oxygen saturation, placed the resident on a non-rebreather mask, and administered an Ipratropium breathing treatment due to “junky” lung sounds. When asked, the NP acknowledged she had not documented this assessment, the respiratory distress event, or the treatment in the medical record and stated she would document it after the interview.
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