Deficiency in Respiratory Care Documentation and Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required supplemental oxygen. The resident, who was severely cognitively impaired, was receiving oxygen therapy without a proper physician's order specifying the liter flow rate or route of administration. The facility's policy required a detailed order for oxygen therapy, including the type of administration system, flow rate, and monitoring parameters. However, the only order available was to titrate oxygen to maintain saturation above 92%, without specifying the necessary details. Observations revealed that the resident was receiving oxygen at 4 liters per minute via nasal cannula, which was not documented in the resident's comprehensive care plan or the Treatment Administration Record. Interviews with nursing staff confirmed the lack of a specific order for the oxygen therapy being administered. The deficiency was identified during a recertification survey, highlighting the facility's failure to adhere to its own policy and ensure proper documentation and physician orders for oxygen therapy.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate action(s) taken for the resident(s) found to have been affected include: - Medical Director facilitated in-service education with the provider responsible for entering Resident #281’s supplemental oxygen order. - Director of Nursing or designee reviewed and updated the physician order [REDACTED]. - Director of Nursing or designee conducted an audit of physician orders [REDACTED]. Audit Findings were: Active supplemental oxygen orders contained indication for use, flow rate, and route of administration. Identification of other residents having the potential to be affected was accomplished by: - Residents receiving supplemental oxygen have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Nursing or designee will in-service Licensed Staff and Medical Staff on adhering to Oxygen Therapy Policy by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Nursing or designee will audit 100% of residents receiving supplementary oxygen. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then Monthly x3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing
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