Failure to Implement Physician-Ordered Oxygen Therapy as Outlined in Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents who were receiving oxygen therapy, as required by physician orders and facility policy. Each resident had a documented care plan and physician order specifying the exact oxygen flow rate to be administered via nasal cannula. However, direct observations on multiple occasions revealed that the oxygen flow rates being delivered did not match the physician's orders. For example, one resident with chronic obstructive pulmonary disease and other comorbidities was observed receiving oxygen at 3.5 LPM instead of the ordered 4 LPM. Another resident with similar diagnoses was observed receiving oxygen at both lower and higher rates than prescribed, including an instance where the flow rate was set at 7 LPM instead of the ordered 5 LPM, which was confirmed as an error by the LPN present. A third resident was also observed receiving oxygen at rates above the as-needed order, with staff confirming the settings were incorrect. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the care plans were in place and that staff were expected to follow the physician's orders as outlined in those plans. The facility's own policy requires individualized, comprehensive care plans with measurable interventions and timetables, and specifies that interventions should be implemented as ordered. The failure to administer oxygen therapy according to the care plans and physician orders constituted a deficiency, as it resulted in residents not receiving care and treatment as specified for their medical needs.