Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two residents who were receiving oxygen therapy. Both residents had physician orders specifying the maximum liters per minute (LPM) of oxygen to be administered, but observations revealed that each was receiving a higher LPM than ordered. For one resident with diagnoses including COPD and respiratory failure, the physician's order specified up to 4 LPM of oxygen via nasal cannula, but the resident was observed on multiple occasions receiving 5 LPM. The resident's care plan and medical record did not document the actual LPM being administered, and the resident was unaware of the current setting. For the second resident, who also had COPD and respiratory failure, the physician's order specified up to 5 LPM of oxygen, but the resident was observed receiving 6 LPM on several occasions. The care plan referenced a high flow nasal cannula up to 10 LPM, but the physician's order in effect was for 5 LPM. The resident reported believing she was receiving the correct amount, and her oxygen saturation levels were documented as being within the target range. Interviews with staff revealed that CNAs were not permitted to change oxygen flow rates and relied on nurses for communication regarding changes. However, the LPN on duty confirmed that both residents were on incorrect oxygen flow rates and admitted not checking the settings during morning rounds. The DON also confirmed that physician orders for oxygen were not being followed, as oxygen is considered a form of medication and must be administered as prescribed.