Inconsistent Oxygen Therapy and Lack of Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. The resident was observed receiving oxygen at a flow rate of 5 liters per minute, which was not consistent with the physician's order of 3 to 4 liters per minute. This discrepancy was noted over several days, and there was no documented evidence in the electronic medical record of a physician's order to increase the oxygen flow rate. Additionally, the facility did not document when the oxygen tubing was last changed for the resident, as required by their policy. Licensed Practical Nurses and the Registered Nurse were unaware of the change in oxygen flow rate and could not provide information on when the tubing was last changed. The Director of Nursing Service confirmed that oxygen should be administered as per the physician's order and that tubing should be changed weekly and dated, but this was not being documented in the medical record.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - The DON and ADON on 12/04/2024 and 12/05/2024 immediately assessed and informed resident #36 and all other applicable residents to ensure they were receiving oxygen at the correct flow rate or replace any oxygen tubing as outlined in the physician’s order. The IDT team simultaneously reviewed resident #36 care plans and checked for any adverse effects due to the incorrect flow rate. - The Physician Assistant performed a general evaluation on 12.05.2024 to identify any symptomatic or chief complaints as a result of the error. No adverse effects were identified as of 01/02/2024. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - The Facility’s Policy and Procedure titled Oxygen therapy was reviewed by the IDT team on 12/12/2024. No amendments were made. - The compliance team and DON created and enforced the respiratory care policies dated 12/12/2024 to include verification of oxygen flow rates against physician orders [REDACTED], scheduled changes of oxygen tubing with proper documentation and labeling. - As of 01/02/2024, 100% direct nursing care staff (RNs and LPNs) were in-serviced on the respiratory care policy, ensuring oxygen flow rates align with physician orders [REDACTED]. - Audit tool created. Quality Assurance Monitoring: - The ADON will perform weekly audits for the first month, then monthly thereafter. Audit results will be reviewed in monthly QAPI meetings to assess compliance and determine if further action is necessary. Responsible Party: Assistant Director of Nursing Services