Failure to Follow Physician 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 multiple respiratory diagnoses, including acute and chronic respiratory failure, asthma, COPD, and pneumonia. The facility's policy required staff to check the clinical record for the physician's order and set the oxygen flow meter to the ordered rate. However, observations on multiple occasions showed that the resident was receiving oxygen at 4 liters per minute (LPM) via nasal cannula, while the physician's order specified 3 LPM as needed. Interviews with staff confirmed that the oxygen was set higher than ordered, and the unit manager stated that staff are expected to follow physician orders and ensure the correct oxygen flow rate. The resident was cognitively intact, as indicated by a BIMS score of 15, and was documented as receiving oxygen therapy in the medical record. The failure to adhere to the ordered oxygen flow rate constituted a deviation from both physician orders and facility policy.