Failure to Maintain Current Physician's Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including acute respiratory failure with hypoxia and pneumonia had a physician's order for continuous oxygen at 1 liter per minute via nasal cannula. Despite this order, multiple observations over several days showed the resident was not receiving oxygen, and the oxygen machine in the room was not in use. The resident confirmed not having received oxygen, and there was no documentation of refusal of treatment in the nurse's notes. The care plan did not include interventions for respiratory care, nor did it document any refusal behaviors. Interviews with staff revealed that the resident had been titrated off oxygen the previous week, but the physician's orders had not been updated to reflect this change. Nursing staff acknowledged responsibility for ensuring orders are accurate and implemented as written. The Director of Nursing Services (DNS) stated that orders should be updated immediately when changes occur but could not explain why the resident was not receiving oxygen as ordered or why the orders were not current. The physician's order was only updated after inquiry to reflect as-needed oxygen administration.