Failure to Follow Physician Orders and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. One resident was observed receiving oxygen at a rate greater than 5 liters per minute via nasal cannula, despite the physician's order specifying administration at 2 liters per minute as needed, with titration up to 5 liters per minute to maintain oxygen saturation at or above 92%. The registered nurse present was unsure of the correct oxygen flow rate and confirmed that the resident was receiving more than the ordered amount. The Director of Nursing also confirmed that staff are required to follow physician orders for oxygen administration. Additionally, the facility did not ensure that oxygen tubing and humidifiers for three residents were labeled with the date and time of the last change, as required by both physician orders and facility policy. Observations and interviews revealed that the oxygen tubing and humidifiers in use for these residents lacked proper labeling, and staff were unable to confirm when the equipment was last changed. The facility's policy and care plans for these residents specified that oxygen tubing should be changed weekly and labeled accordingly. The residents involved had significant medical histories, including dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure, and other chronic conditions requiring continuous or as-needed oxygen therapy. The lack of adherence to physician orders and facility protocols regarding oxygen administration and equipment maintenance was confirmed through staff interviews, record reviews, and direct observation.