Failure to Follow Physician Orders for Oxygen Therapy and Humidification
Penalty
Summary
Facility staff failed to follow physician orders regarding oxygen therapy for a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and dependence on supplemental oxygen. The resident was observed multiple times with oxygen administered at five liters per minute via nasal cannula, despite a physician order specifying four liters per minute. The resident was cognitively intact and dependent on staff for most activities of daily living, and there was no evidence that she or her family adjusted the oxygen flow rate. Additionally, the humidity bottle attached to the oxygen concentrator was repeatedly found empty and not changed as required by physician order and facility policy, which called for weekly changes and as-needed replacement every shift. Nursing documentation indicated that the resident experienced a drop in oxygen saturation to 87 percent, prompting an increase in oxygen flow to five liters per minute and administration of an inhaler. However, there was no documentation that the physician was notified of this change in respiratory status or the adjustment in oxygen flow rate, as required by both physician order and facility policy. Staff interviews confirmed that the oxygen flow rate and humidification were not maintained per orders, and the physician was not notified of the changes. The facility's policy required oxygen to be administered according to physician orders and for staff to notify the physician of any changes in the resident's condition or oxygen administration.