Oxygen Administration Deficiency
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident, who had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute. Observations during the recertification survey revealed that the resident was receiving oxygen at a rate of 2.5 liters per minute, which was not in accordance with the physician's order. Additionally, there was no signage indicating oxygen use on the door of the resident's room, as required by the facility's policy. Interviews with facility staff, including a Licensed Practical Nurse and a Registered Nurse Supervisor, confirmed the discrepancy in oxygen administration and the absence of required signage. The LPN acknowledged the fluctuation in the oxygen rate and the RN Supervisor confirmed that signage should have been posted. The Director of Nursing stated that physician orders for oxygen use were mandatory, except in emergencies, and that signage should be present when oxygen is in use. The deficiency was identified as a failure to adhere to the physician's order and facility policy regarding oxygen administration and signage.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 695 P(NAME) Description: I. Immediate Corrective Action Resident #34 was assessed by MD to ensure there were no negative effects. Resident #34 was provided with a new concentrator; one that has the liter flow consistently matching the doctor's order. II. Resident #34 now has a sign outside the room with the appropriate oxygen signage. III. Identification of others a. All residents on O2 were evaluated to ensure that oxygen delivery was consistent with MD order. No other residents were noted with this deficiency. b. All rooms with residents receiving oxygen were audited to ensure they have the proper signage. No other resident rooms were found to be lacking proper signage. IV. Systematic Changes a. Policy and procedure regarding obtaining a MD order for oxygen usage was reviewed and found to be in compliance. An in-service was provided to all RNs and LPNs on ensuring that oxygen delivery is in accordance with doctor's orders. V. QA monitoring a. An audit tool was developed to ensure that all residents on oxygen are being given the prescribed setting. b. Audit will be conducted by RNs on residents receiving oxygen weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. c. Audits shall be brought to QA meeting to review with the team. VI. Title Responsible a. Director of Nursing.