Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with congestive heart failure, chronic obstructive lung disorder, and anemia. The resident was observed receiving oxygen therapy at incorrect flow rates on multiple occasions. Initially, the resident was seen receiving oxygen at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Later, the resident was observed receiving oxygen at 4.5 LPM, which was also incorrect. The resident's assigned nurse confirmed that the physician's order specified a continuous flow rate of 2 LPM via a nasal cannula. The nurse acknowledged responsibility for setting and monitoring the oxygen flow rate and suggested that someone might have accidentally adjusted it. The facility's procedure required staff to verify the physician's order before setting the flow rate, but this was not adhered to, leading to the deficiency.
Plan Of Correction
1. Corrective Action of Areas Affected: For resident #6, orders have been updated to check the Ex Order26.451 being administered every shift by the nurse. 2. Other Areas Affected: All residents requiring oxygen have the potential to be affected by the deficient practice. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing/designee has re-educated the licensed nursing staff on the oxygen administration policy. The Director of Nursing/designee has conducted an initial audit for residents with physician orders for oxygen to validate oxygen is being administered as per MD order. 4. Monitoring of Corrective Action: The Director of Nursing/designee will complete random observations of residents with oxygen orders to verify oxygen is being administered as per the MD order weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly at the Quality Assurance Improvement Meetings for review and recommendations.