Failure to Implement and Document Physician-Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not implementing and documenting a physician’s order for oxygen therapy for one resident. The resident was readmitted to the facility from the hospital with convalescent care orders dated 02/13/26 that included an order for oxygen at 2.5 liters per minute. Review of the resident’s medical record showed that this oxygen order was not entered into the resident’s active orders. Subsequent observations of the resident’s room revealed there was no oxygen concentrator or oxygen delivery equipment present, and observation of the resident in the dining room showed the resident did not have an oxygen tank or nasal cannula in use. During interviews, an LPN confirmed that the resident did not have an oxygen order in the medical record despite the convalescent care orders specifying oxygen at 2.5 LPM, and acknowledged that the resident had not been placed on oxygen after returning from the hospital. The LPN also stated that staff were expected to enter all convalescent care orders into the medical record upon a resident’s return from the hospital. The DON similarly confirmed that staff were expected to review all convalescent care orders, enter them into the resident’s medical record, and ensure all orders were implemented, which did not occur in this case.
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