Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with multiple respiratory conditions, including respiratory failure with hypoxia, COPD, and heart failure. The resident, who had severely impaired cognition, was readmitted from an acute care hospital with an order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The resident's care plan also directed nurses to administer oxygen therapy as ordered by the physician. During an observation, the oxygen concentrator for the resident was found set at 3 LPM instead of the ordered 2 LPM. This discrepancy was confirmed by a registered nurse, who acknowledged the physician's order and stated that she had not yet checked the setting during her shift. The Director of Nursing confirmed that staff were expected to verify oxygen settings against physician orders. The facility's policy required oxygen to be provided according to physician orders.