Inappropriate Oxygen Administration for Resident with COPD
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and dependent on supplemental oxygen. The resident was admitted to the facility on September 1, 2022, and had a physician's order for oxygen at 2 Liters/Min via nasal cannula to be administered continuously every shift. However, on February 4, 2025, at 11:38 a.m., it was observed that the resident was receiving oxygen at 4 Liters/Min, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing.
Plan Of Correction
1. R38's oxygen was immediately adjusted to reflect the physician's order for 2 liters/min via nasal cannula at the time of notification. R38 experienced no ill effects from this event. 2. The Director of Nursing or designee will conduct an audit on current residents who are ordered oxygen to ensure compliance with physician's orders by 2/28/25. 3. The Director of Nursing or designee will provide re-education to current licensed staff on the "Oxygen Policy" and "Physician Orders Policy," including the requirement to adhere to the orders of the prescriber by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on up to 5 residents who are ordered oxygen to ensure compliance with the physicians/providers' orders weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.