Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with intact cognition and multiple diagnoses, including atrial fibrillation, chronic obstructive pulmonary disease, coronary artery disease, and heart failure. The resident was observed receiving oxygen at a setting of 3 liters, contrary to the physician's order of 2 liters to maintain oxygen saturation at or above 89%. The Medication Administration Review (MAR) sheets indicated discrepancies in the recorded oxygen settings, with an unauthorized change to 3 liters documented in February 2025, and no subsequent adjustments or updates to reflect the physician's order. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen settings. A Licensed Practical Nurse (LPN) was unable to recall the current oxygen order and noted that the resident typically received 3 liters, based on their assessment of the resident's comfort. The facility lacked a protocol or standing orders for titrating oxygen settings, requiring nursing staff to contact the physician for any changes. The facility's policy on oxygen therapy administration, revised in October 2022, mandates that the oxygen flow rate be set to the prescribed dosage, which was not followed in this case.