Failure to Administer Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure the application of physician-ordered supplemental oxygen consistent with professional standards of practice for a resident. On two separate occasions, the resident was observed receiving supplemental oxygen at a flow rate of three liters per minute, despite having an active physician order for two liters per minute. The resident, who had a history of chronic respiratory failure and COPD, believed her oxygen was set correctly at three liters per minute. The plan of care required oxygen saturations to be checked and recorded every eight hours and as needed, with oxygen administered per the physician's order. A licensed practical nurse (LPN) mistakenly believed she was permitted to adjust the oxygen flow based on the resident's oxygen saturation levels, although the physician's order did not allow for such titration. Upon review, the LPN corrected the oxygen flow to align with the physician's directive. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the discrepancy between the physician's orders and the actual administration of oxygen to the resident.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 15's orders were changed by the physician to a titrate order. There was no harm to resident 15. 2. All residents with supplemental oxygen orders were reviewed and confirmed for wean vs titrate. 3. Education to licensed staff on titrate vs wean orders for supplemental oxygen. 4. Random audit of 5 residents on supplemental oxygen to ensure their oxygen setting follows their order. 5. Compliance date: January 28, 2025.