Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for four residents. In multiple instances, residents were observed receiving oxygen at flow rates different from those prescribed. For example, one resident with COPD and a physician order for 2 L/min via nasal cannula was observed receiving oxygen at 4 L/min and later at 2.75 L/min. The resident’s care plan and orders specified the required oxygen settings, but these were not followed during observations. The Director of Nursing confirmed that the oxygen concentrator was not set to the ordered rate and was unsure if staff knew how to read the flowmeter. Another resident was observed receiving 2.5 L/min of oxygen, but the active physician order did not specify a flow rate. The care plan contained conflicting interventions, listing different flow rates (2 L/min, 2.5 L/min, and 4 L/min), and staff were unable to locate the correct order in the system. Staff interviews revealed uncertainty about the correct oxygen parameters, and a new order was only entered after the deficiency was identified. In a separate case, a resident with a tracheostomy was receiving 3 L/min of humidified oxygen, but the physician order specified 28% humidified oxygen without a corresponding liter flow. Staff were unable to locate the specific order for the oxygen flow rate and expressed uncertainty about the correct setting. Additionally, another resident was observed receiving 1.5 L/min of oxygen, while the physician order had previously specified 4 L/min as needed and 2 L/min for ambulation, both of which had been discontinued. The care plan referenced following orders for oxygen therapy, but the observed administration did not match any active order. The facility’s policy on oxygen administration outlined procedures for infection control and documentation but did not address the discrepancies in following physician orders for oxygen flow rates.