Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide consistent respiratory care and supplemental oxygen as ordered by the physician for two residents. Resident R2, who was admitted with chronic respiratory failure with hypoxia and congestive heart failure, had a physician's order for oxygen at 3 liters/min via nasal cannula continuously. However, during an initial facility tour, it was observed that the oxygen level was set at 1.5 liters on the resident's oxygen concentrator. This discrepancy was confirmed by a licensed nurse, indicating that the incorrect amount of oxygen was being administered. Similarly, Resident R5, diagnosed with chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters/min via nasal cannula continuously for shortness of breath. Observations revealed that the resident was not receiving oxygen as prescribed, as the valve connected to the oxygen tank was not turned on. This was confirmed by the Director of Nursing, highlighting a failure to adhere to the physician's orders for oxygen therapy.
Plan Of Correction
1. Residents R2 and R5 were provided with respiratory care and supplemental oxygen as ordered by the physician. 2. Residents on oxygen will be audited to ensure they are following MD orders. 3. Staff will be educated on the components of this regulation with an emphasis on providing appropriate respiratory and tracheostomy care. 4. 3 residents on oxygen will be audited to ensure they are following MD orders 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.