Failure to Ensure Nursing Staff Competency in Oxygen Administration
Penalty
Summary
Licensed nursing staff failed to demonstrate competency in administering oxygen to a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted and readmitted with a diagnosis of COPD and required supplemental oxygen. However, after the physician's order for oxygen was discontinued, nursing staff continued to provide oxygen to the resident upon request, without a current physician's order specifying the amount or monitoring requirements. Documentation showed that oxygen saturations were only recorded twice after the order was discontinued. The nurse involved could not recall receiving training on oxygen administration, oxygen orders, or monitoring. Interviews with facility leadership revealed that the in-service training provided to nursing staff did not cover essential topics such as validating physician orders for oxygen, monitoring requirements, or titration of oxygen. The Director of Nursing acknowledged that staff should be trained and in-serviced on these aspects to ensure proper use of oxygen. The facility's policy on in-service training stated that staff should demonstrate competency in training topics, but this was not reflected in the training provided regarding oxygen administration.