Failure to Ensure Ordered Oxygen Therapy Was Provided
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with physician-ordered oxygen therapy actually received oxygen as ordered. The resident had COPD, CHF, a history of pressure ulcers, severely impaired cognition, was oxygen dependent, and dependent for all care. A physician’s order directed oxygen at 0–4 liters to maintain oxygen saturation above 92% and required oxygen saturation checks every shift. The resident’s care plan included interventions to administer medications as ordered, change oxygen and nebulizer tubing as ordered, monitor oxygen saturation as ordered, and check portable oxygen tank levels every three hours when in use. The MAR for January and February documented continuous oxygen administration and shift oxygen saturation readings. Despite these orders and documentation, interviews and observations showed that oxygen was not consistently provided as ordered. A visitor reported seeing the resident on multiple occasions using a portable oxygen tank that contained no oxygen and noted that unused portable tanks were often empty. During an observation, the resident was found in bed with the nasal cannula not in place, the oxygen concentrator powered off, and the oxygen tubing placed on top of a dresser out of the resident’s reach. Staff interviews revealed that a NA had fed the resident earlier and stated the oxygen was on at that time, and an LPN reported administering a nebulizer treatment earlier with oxygen in use and documented saturations of 95% and 98%. Both the NA and LPN stated they did not know why the oxygen was off and confirmed the oxygen should have been on, and the DON reported seeing the resident earlier with oxygen on and stated no one should have turned it off. When the LPN checked the resident’s oxygen saturation before reapplying oxygen, it was 90%, below the ordered threshold of above 92%. The facility’s policy stated oxygen is to be administered per physician’s orders.
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