Failure to Maintain Clear and Authorized Oxygen Therapy Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not having clear or complete oxygen orders for multiple residents. One resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to keep oxygen saturation above 90%, but the order did not specify when the oxygen should be used. During observation, this resident was not wearing oxygen and the concentrator was off; the resident stated she only wears oxygen when she needs it. The DON confirmed that the resident only wears oxygen as needed and that the order did not specify when oxygen should be worn, acknowledging that it should. Another resident with CHF, chronic respiratory failure with hypoxia, major depressive disorder, A-fib, sleep apnea, and atherosclerotic heart disease had an order for 2 L of oxygen via nasal cannula with titration to maintain oxygen saturation at 92%, but the order did not indicate whether oxygen was to be administered continuously or PRN. The DON confirmed this lack of specificity and stated the order should indicate when to administer oxygen. A third resident with hypertension, kidney failure, DM2, cellulitis of the right lower limb, and metabolic encephalopathy was observed lying in bed wearing a nasal cannula connected to an oxygen concentrator. The ADON confirmed the resident was on oxygen, and the DON later confirmed that this resident did not have a medical order for oxygen use, despite using supplemental oxygen.
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