Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for a resident with diagnoses including Parkinson's disease, restlessness and agitation, and squamous cell carcinoma. Multiple observations over several days showed that the resident's oxygen concentrator was turned off and the nasal cannula was not in use, despite a physician's order to titrate oxygen via nasal cannula between room air and 2LPM to maintain oxygen saturation at or above 90% every shift. On subsequent days, the resident was observed receiving oxygen at 5LPM, which exceeded the physician's order. Staff interviews confirmed that the oxygen was set at 5LPM and that the resident's oxygen saturation was 95%. Upon realizing the discrepancy, staff adjusted the oxygen flow to 2LPM as per the order. The Director of Nursing confirmed that any change in oxygen administration outside of the physician's order would require a new order. Review of facility policy indicated that physician orders and progress notes should be maintained according to regulations, but the policy did not specifically state that physician orders must be followed. The deficiency was identified due to the failure to administer oxygen as prescribed and to ensure staff adhered to the physician's orders for respiratory care.