Inappropriate Oxygen Administration for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident diagnosed with Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Atelectasis. The resident was ordered to receive oxygen at 2 Liters/Min via nasal cannula as needed. However, on two separate occasions, the resident was observed receiving oxygen at 3 Liters/Min, which was not in accordance with the physician's order. This discrepancy was confirmed by a Licensed Nurse at the time of the findings.
Plan Of Correction
Resident R158 is receiving her PRN oxygen at 2L/minute per physician orders. DoN / Designee to conduct initial audit on residents receiving oxygen therapy to ensure accurate liters/minute per physician orders. NPE/DON/Designee to re-educate professional nurses to ensure physician orders followed for liters/minute for residents receiving oxygen therapy. DON / Designee to conduct weekly audits X 4 then monthly X 2 on 5 random residents receiving oxygen to ensure accurate liters/minute per physician orders. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.