Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to physician orders for two residents who required respiratory care. In the first case, a resident with multiple diagnoses including COPD, morbid obesity, and diabetes was observed receiving oxygen at 3.5 L/min via nasal cannula on two separate occasions, despite an active physician order specifying continuous oxygen at 5 L/min. The resident was cognitively intact and aware of his oxygen needs. Documentation confirmed the physician's order for 5 L/min, and the care plan included interventions to administer oxygen as ordered. Interviews with nursing staff revealed that LPNs were trained to set the oxygen flow rate per order and were expected to check the flow rate each time they entered the room, while CNAs were responsible only for ensuring the oxygen was running and properly placed. The DON was unable to provide details on the facility's policy for monitoring oxygen flow rates during the survey. In the second case, another resident with chronic respiratory failure, COPD, and dependence on supplemental oxygen was observed receiving oxygen at 3 L/min via nasal cannula on two occasions, while the physician's order specified continuous oxygen at 4 L/min. This resident had severe cognitive impairment and required significant assistance with daily activities. The care plan addressed the resident's oxygen dependence and risk for impaired gas exchange, and the physician's orders included specific instructions for oxygen therapy and monitoring. No oxygen signage was present on the resident's door during observations. A review of the facility's oxygen therapy policy confirmed that oxygen administration should follow the physician's specified flow rate. The policy also required a "No Smoking" sign as part of the equipment for oxygen therapy. The survey found that the facility did not ensure oxygen was administered at the ordered flow rates for both residents, and staff interviews indicated a lack of clarity regarding the frequency and responsibility for monitoring oxygen flow rates.