Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R45, who was receiving oxygen therapy. Resident R45 was admitted with diagnoses including pulmonary hypertension, chronic obstructive pulmonary disease, and chronic respiratory failure. The physician's orders for Resident R45 specified the administration of oxygen at 1 liter per minute via nasal cannula to maintain blood oxygen levels above 92%. However, observations on two separate occasions revealed that the resident was receiving 2 liters of oxygen, contrary to the physician's orders. Additionally, it was noted that the oxygen tubing used for Resident R45 was not dated, which is a deviation from standard practice. This was confirmed during an interview with a licensed nurse, Employee E3, who acknowledged that the oxygen concentrator was set at 2 liters and that the tubing was undated. These findings indicate a failure to adhere to the prescribed oxygen therapy regimen and proper equipment management, as required by professional standards and the resident's care plan.
Plan Of Correction
1. Resident R45's oxygen concentrator setting was placed at 1 Liter as ordered by the physician. The oxygen tubing was changed and dated. 2. All residents' oxygen concentrator settings have been evaluated and are administering the proper liters of oxygen according to the physician orders. All oxygen tubing's were changed and dated. All residents on oxygen will receive physician orders to change and date oxygen tubing weekly. 3. All licensed staff will be re-educated on physician's orders and concentrator settings. The Director of Nursing/Designee will review the new orders report for oxygen orders and accurate concentrator settings. 4. The Director of Nursing/Designee will perform random weekly audits times 4, then monthly audits times 4, then quarterly audits times 4 of physician's orders for oxygen orders and for accurate concentrator settings. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance. 5. Date of Corrective action: May 30, 2025.