Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident diagnosed with chronic obstructive pulmonary disease (COPD) with an acute exacerbation. Clinical record review showed that the resident was admitted with this diagnosis and had a current physician order for continuous oxygen administration at 1.5 liters per minute (LPM) via nasal cannula. However, observations on two separate days revealed that the resident was receiving oxygen at 2.5 LPM, which was not consistent with the physician's order. This discrepancy was confirmed through review of the clinical records and direct observation of the resident by surveyors. The findings were discussed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
The facility reviewed the orders in relation to the continued oxygen rate for resident #23 and corrective actions were taken. There was no evidence of any ill effect on these residents. A review of the orders for any residents with the diagnosis of chronic obstructive pulmonary disease (COPD) with exacerbation was conducted, and any variances from the order were corrected and noted in the charts. Education was provided by the Director of Nursing or designee on the adherence to the written order for oxygen and the adherence to the facility policy. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months relating to the appropriate management of respiratory care, in particular the monitoring of oxygen levels. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.