Failure to Obtain and Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining required physician orders, not following existing physician orders, and not accurately care planning for oxygen therapy. For one resident with acute respiratory failure and other comorbidities, the facility did not have a physician's order for the ongoing oxygen therapy observed during multiple visits, despite documentation in the care plan. Another resident with respiratory failure and a tracheostomy was observed receiving oxygen at higher flow rates than documented in the care plan, and there was no physician's order specifying the correct oxygen flow rate. The care plan for this resident also did not accurately reflect the oxygen therapy being provided. A third resident with chronic obstructive pulmonary disease had a physician's order for oxygen at 2L/min via nasal cannula, but was observed receiving oxygen at 8L/min on two separate occasions. Nursing staff confirmed that the oxygen should have been set at 2L/min as per the physician's order. The DON acknowledged that staff are expected to follow physician orders and ensure care plans are accurate, but these requirements were not met for the residents reviewed.