Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. The resident was observed receiving oxygen at three liters per minute, while the physician's order specified four liters per minute. The resident was not aware of the prescribed oxygen setting, stating that the nurses handled it. A licensed nurse confirmed the oxygen was set incorrectly and verified the physician's order for four liters per minute. The care plan also directed staff to administer oxygen as ordered by the physician. Further review and interviews with the respiratory therapist and the Director of Nursing confirmed that there was no order to titrate the oxygen and that the expectation was to follow the physician's order exactly. Facility policy required oxygen to be administered under a physician's order. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Plan Of Correction
b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025