Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by physicians for three residents with significant respiratory and cardiac diagnoses. For one resident with chronic obstructive pulmonary disease (COPD), pulmonary candidiasis, and atrial fibrillation, physician orders specified oxygen at 5 liters per minute (LPM) via nasal cannula (NC), but observations showed the resident receiving oxygen at 3.5 LPM and, at another time, at 7 LPM. The LPN confirmed the flow rate was set incorrectly and adjusted it. Another resident with COPD and a cardiac defibrillator had an order for oxygen at 2 LPM via NC as needed for shortness of breath, but was observed receiving oxygen at 3.5 LPM and later at 4 LPM. The LPN confirmed the oxygen was not set per the physician's order. A third resident with multiple diagnoses, including endometrial cancer, heart failure, and dependence on supplemental oxygen, had an order for 4 LPM via NC, but was observed receiving 3.5 LPM. The DON and LPN both confirmed the oxygen was not set as ordered. Facility policy required medications and treatments, including oxygen, to be administered only as ordered by a licensed prescriber and for staff to verify and adjust oxygen flow rates according to physician orders. Despite these policies, staff did not consistently monitor or set oxygen flow rates as prescribed, as confirmed by direct observation, staff interviews, and record review. The DON stated that her expectation was for licensed nurses to monitor and ensure oxygen settings matched physician orders, but this was not consistently done.