Failure to Ensure Proper Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who were receiving oxygen therapy. For one resident, observations showed that oxygen was administered via nasal cannula at 2 liters per minute on multiple occasions, but the physician's order only stated 'Oxygen For comfort' without specifying a flow rate. The Director of Nursing confirmed that the order should have included the flow rate, and the LPN interviewed stated that a specific flow rate is expected, especially for residents with COPD, to avoid hyper-oxygenation. For the second resident, observations also showed oxygen being administered at 2 liters per minute via nasal cannula, but there was no physician order for oxygen administration, only an order for oxygen tubing changes. The DON acknowledged the absence of an oxygen order, and a registered nurse stated that orders should be present in the system when a patient is on oxygen. The facility's policy requires that physician orders for oxygen therapy include the administration modality, flow rate, and specific guidelines for use, which was not followed in these cases.