Failure to Obtain and Follow Physician Orders for Non-Rebreather Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, specifically the use of a non-rebreather mask for high-flow oxygen therapy, received care consistent with professional standards, physician orders, and the resident's care plan. The resident, an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD, was on hospice care and dependent on staff for all activities of daily living. Her care plan and physician orders specified oxygen therapy via nasal cannula at 2-4 liters per minute, but did not include orders for non-rebreather mask use or high-flow oxygen therapy. On several occasions, nursing staff and hospice personnel initiated the use of a non-rebreather mask for the resident when she experienced shortness of breath and low oxygen saturation. However, there was no documented physician order for this intervention, and the mask was set at oxygen flow rates below the recommended minimum for non-rebreather use (less than 10 liters per minute) for an extended period. Staff interviews revealed confusion and lack of familiarity with the appropriate use and settings for non-rebreather masks, as well as uncertainty about the process for obtaining and documenting physician orders for changes in oxygen delivery methods. The non-rebreather mask remained in use for several days without proper orders or adjustment to the correct oxygen flow rate, and the care plan was not updated to reflect this change in therapy. Documentation and interviews further indicated that communication between facility staff, hospice nurses, and respiratory therapists was inconsistent. Some staff assumed that existing oxygen orders covered the use of a non-rebreather mask, while others believed that emergency use did not require a new order. The Director of Nursing and other staff acknowledged that physician orders are required for all oxygen delivery methods, but this was not consistently followed. The lack of specific orders and failure to follow professional standards for respiratory care placed the resident at risk for inappropriate oxygen therapy.