Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for oxygen administration for a resident with chronic respiratory failure and congestive heart failure who was admitted to hospice care. Observations revealed that the resident was receiving oxygen at 3 liters per minute via nasal cannula, despite the physician's order specifying 2 liters per minute continuously and 4 liters per minute as needed. There was no order for oxygen at 3 liters per minute, and documentation did not support titration based on the resident's needs or comfort. Interviews with nursing staff indicated that adjustments to the oxygen flow were made based on the resident's oxygen saturation and reported needs, but the resident was unable to adjust the oxygen herself. Record reviews showed inconsistencies between the facility's documentation and the hospice communication book regarding the prescribed oxygen flow rates. The facility's policy required adherence to prescriber orders, but this was not followed in the resident's care.