Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents by not following physician orders for oxygen administration. For one resident, the oxygen concentrator was set at three liters per minute (LPM), but the nasal cannula was not in the resident's nose, and there was no documentation in the medical record or medication administration record (MAR) to indicate that oxygen was needed or administered as ordered. The resident's physician order specified oxygen at two LPM via nasal cannula as needed for shortness of breath, with titration to maintain oxygen saturation at or above 90%, and required documentation of administration and the reason for use. However, there was no evidence of shortness of breath, low oxygen saturation, or documentation of PRN oxygen administration in the records. Additionally, another resident was observed receiving six LPM of oxygen via nasal cannula, while the physician's order specified continuous oxygen at two LPM. A third resident was observed receiving five LPM of oxygen, despite a physician's order for three LPM. In both cases, staff verified that the oxygen being administered did not match the physician's orders. These discrepancies were confirmed through observation, staff interviews, and medical record reviews, indicating a failure to ensure that oxygen therapy was provided as prescribed.