Failure to Follow Oxygen Administration Orders and Documentation Protocols
Penalty
Summary
The facility failed to follow physician orders and its own policies regarding the administration and documentation of supplemental oxygen for four residents. For three residents, oxygen was administered at higher flow rates than prescribed by their physicians. Specifically, one resident with an order for continuous oxygen at 2 liters per minute (LPM) was observed receiving 5 LPM, while two other residents with orders for 2 LPM PRN were observed receiving 4 LPM and 3 LPM, respectively. Nursing staff confirmed that they had not adjusted the oxygen flow during their shifts, and medical record reviews verified that the physician orders were not followed. For another resident, there was a lack of proper documentation regarding the administration of PRN oxygen. Although the medical record and various nursing summaries indicated that the resident received oxygen daily over a period of several weeks, the Medication Administration Record (MAR) only documented a single instance of PRN oxygen administration. Interviews with nursing staff and the Director of Nursing confirmed that the resident was on continuous oxygen, despite the physician's order specifying PRN use, and that the MAR did not accurately reflect the frequency of administration. These deficiencies were identified through direct observation, interviews with nursing staff, and review of medical records and facility policies. The facility's policies required that oxygen be administered as ordered by the physician and that all medication administration be properly documented. The failure to adhere to these protocols resulted in both inaccurate administration of oxygen and incomplete documentation for the affected residents.