Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary manifestations due to radiation, pneumonia, and influenza. The resident's care plan and physician orders specified oxygen administration via nasal cannula at 4 liters per minute during ambulation and 2 liters per minute at rest. However, during multiple observations, the resident was found sitting in a wheelchair in their room with the oxygen concentrator set at only 1 liter per minute, which was not consistent with the prescribed orders. These observations were confirmed on three separate occasions, including one in the presence of the Director of Clinical Excellence, who acknowledged that the physician's order for supplemental oxygen was not being followed. The clinical record and care plan documentation supported the need for specific oxygen settings, but staff did not adhere to these requirements during the survey period.