Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure was observed receiving oxygen therapy via nasal cannula at 3 liters while awake and in common areas. The resident's care plan indicated a need for oxygen administration as ordered by the physician, and the May 2025 Physician's Order Summary specified oxygen at 3 liters per nasal cannula only while sleeping or napping, every shift. However, observations showed the resident receiving oxygen continuously, not limited to sleep or nap times as per the physician's order. Interviews with staff revealed a lack of clarity regarding the physician's order, with an LPN stating the resident needed oxygen at all times and indicating the need to clarify the order with the physician. The facility's policy required verification of physician orders and knowledge of flow rate and duration of use, but the resident was not receiving oxygen therapy in accordance with the documented physician order at the time of the survey.