Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for one resident. According to facility policy, staff are required to verify and document the physician's order for oxygen, including the prescribed liter flow, delivery device, and duration. Medical record review showed that the resident, who had diagnoses of chronic obstructive pulmonary disease, respiratory failure, dementia, palliative care, and heart failure, had a physician's order for oxygen at 3 liters per minute via bi-nasal cannula every shift. However, multiple observations over two days revealed the resident was receiving oxygen at a flow rate of only 2 liters per minute. During an interview, the Director of Nursing confirmed that the oxygen flow rate should match the physician's order and that staff are expected to follow these orders.