Failure to Follow Physician Orders and Infection Control for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident by not following the physician's order for oxygen therapy and not adhering to the required schedule for changing the oxygen nasal cannula. The resident, who had diagnoses including congestive heart failure, COPD, pleural effusion, and malignant neoplasm of the pleura, was observed receiving oxygen at a flow rate of 4.5 liters per minute (lpm) via nasal cannula, despite a physician's order specifying continuous oxygen at 3 lpm with titration to maintain oxygen saturation above 92%. Multiple observations confirmed the oxygen was set at 4.5 lpm, and there was no documentation of titration or communication with the physician regarding adjustments, as required by the order. Additionally, the resident's physician's order required the oxygen tubing and nasal cannula to be changed once a week and labeled accordingly. However, the nasal cannula in use was labeled with a date more than two weeks prior, indicating it had not been changed as ordered. Staff interviews confirmed awareness of the requirement to change the nasal cannula weekly for infection control, but this was not done for the resident in question. Facility policy and procedures for oxygen administration and infection prevention were not followed, as staff did not verify or adhere to the physician's orders for oxygen flow rate, titration, and documentation, nor did they ensure timely replacement of the nasal cannula. These failures were confirmed through staff interviews and review of facility policies, which outlined the expectations for oxygen therapy and infection control practices.