Failure to Follow Physician Orders for Oxygen Therapy
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to follow physician orders for respiratory care for a resident with chronic respiratory failure and hypoxia. According to the clinical record, the resident had a physician order for a tracheostomy collar with 28% humidified oxygen delivered via a concentrator set at 2L/min. During an observation, the resident was found not to be receiving the ordered two liters of oxygen. Staff interviews confirmed that the tracheostomy setup had not been changed since the last check earlier that morning, and the nurse was able to recite the correct order but did not ensure it was being followed. This failure resulted in the resident not receiving the prescribed oxygen therapy as ordered by the physician.