Failure to Follow Physician Orders for Oxygen and Medication Administration
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of quality in several instances. One resident with chronic obstructive pulmonary disease (COPD) and a history of obstructive sleep apnea was observed receiving oxygen therapy at a rate of 1 liter per minute via nasal cannula, contrary to the physician's order for 2 liters per minute as needed to maintain oxygen saturation above 92%. Documentation of oxygen saturation was not completed on the day of observation, and the last recorded value was two days prior. The care plan and facility policy required adherence to the physician's order and proper documentation, which was not followed. In another instance, a resident prescribed Glipizide 10 mg tablet for type 2 diabetes mellitus was administered the medication after breakfast, despite the physician's order specifying administration before breakfast. The nurse confirmed that the medication was given at the incorrect time, as breakfast had already been completed prior to administration. This action was not in accordance with the prescriber's parameters for medication timing. Additionally, a resident with an order for two Lidocaine 5% patches to be applied to the right shoulder and right rib area for pain received one patch incorrectly applied to the mid-lower back. The nurse acknowledged the error and corrected the application after it was identified. The facility's policy on medication administration required adherence to the six rights, including correct route and site, which was not followed in this case.