Failure to Administer Oxygen Therapy as Ordered for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident who required respiratory care did not receive oxygen therapy as ordered by the physician. The resident, who had a history of cardiac arrest, acute respiratory failure with hypoxia, anoxic brain damage, cerebrovascular disease, and dependence on supplementary oxygen, was observed with a tracheostomy and was completely dependent on staff for all activities of daily living. The physician's order specified that the resident should receive 4 liters per minute (LPM) of oxygen via tracheostomy, with no titration order in place. During multiple observations, the resident was found to be receiving 4.8 LPM of oxygen instead of the ordered 4 LPM. Nursing staff, including an RN, failed to check or adjust the oxygen flow rate at the start of their shift and were unaware that the resident was receiving more oxygen than prescribed. The RN confirmed that only nurses were permitted to adjust the oxygen settings, and the resident was not physically able to change the settings independently. The care plan also did not specify the required oxygen flow rate as per the physician's order. Interviews with nursing staff and facility leadership confirmed that the physician's order for oxygen was not being followed, and that nurses were responsible for ensuring oxygen was administered according to orders. The facility's policy required verification of physician orders and regular assessment of respiratory status, but these procedures were not consistently followed, resulting in the resident receiving a higher oxygen flow rate than ordered.