Failure to Obtain and Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen administration were obtained and followed for two residents. For one resident with a history of pulmonary embolus, pulmonary fibrosis, and atelectasis, observations showed the resident receiving oxygen at two liters per minute via nasal cannula, despite a physician's order for four liters per minute to maintain oxygen saturation at or above 92%. The discrepancy was confirmed by the DON during a review of the resident's orders, and the order was later changed to two liters per minute. The resident's care plan indicated the need to administer oxygen per physician's orders due to cardiovascular and pulmonary risks. For another resident with chronic respiratory failure, chronic lung disease, and emphysema, observations documented the resident receiving supplemental oxygen between 2.5 and 3 liters per minute via nasal cannula. However, the clinical record did not contain a physician's order specifying the amount of oxygen to be administered. The care plan directed staff to administer oxygen per physician's orders, but no such order was present in the record. Facility policy required verification of a physician's order for oxygen administration.