Failure to Follow Physician's Oxygen Order for Resident with COPD
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who was prescribed oxygen at 3 liters per minute via nasal cannula with humidifier. Multiple observations revealed that the resident was receiving oxygen at 4 liters per minute without the required humidification. The resident reported being unable to check the oxygen settings and relied on staff to ensure accuracy. Staff interviews confirmed awareness of the correct order but acknowledged that the oxygen was set incorrectly and the humidifier was not in use. One LPN admitted to not checking the oxygen settings upon starting her shift.
Plan Of Correction
On 06/18/2025, resident #60 was assessed by the DON/Designee, confirming oxygen delivery is being provided in accordance with physician orders. All residents residing in the facility requiring supplemental oxygen have the potential to be affected. The DON/Designee will review all current residents requiring supplemental oxygen by 07/18/2025 to ensure that oxygen is delivered in accordance with physician orders, with corrective action immediately upon discovery. Licensed nurses will be re-educated by the DON/Designee regarding the delivery of oxygen in accordance with physician orders. This re-education will be completed by 07/25/2025. The DON/Designee will audit ten residents requiring oxygen weekly for four weeks, and then five residents requiring oxygen weekly for eight weeks, to ensure that oxygen delivery is provided in accordance with physician orders. The results of these audits will be submitted to the QAPI committee monthly for review and further recommendations. The overall completion date for these actions is 07/25/2025.