Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were followed for three residents. One resident with heart failure and severe cognitive impairment had a physician order for PRN oxygen to be applied when oxygen saturation fell below 90%. Documentation showed at least two occasions when the resident's oxygen saturation was 89%, but there was no documentation that oxygen was applied. Staff members reported not being aware of the PRN oxygen order, and although they sometimes applied oxygen when low saturations were noted, they did not consistently document its administration. The resident was not observed with oxygen during the survey period, and staff acknowledged not signing for PRN oxygen administration as required. Another resident with cancer, COPD, and severe cognitive impairment had a physician order for oxygen at 2 liters per nasal cannula, later changed to a titration order between 2-4 liters to maintain oxygen saturation above 90%. Observations revealed that the resident was often not wearing oxygen or had the oxygen flow set higher than ordered, sometimes at 3.5 to 4 liters instead of the prescribed 2 liters. Staff reported that the resident frequently removed the oxygen or adjusted the flow rate independently. The facility's documentation did not include a place to record the actual liter flow when titration was ordered, and staff acknowledged this gap in documentation. A third resident with multiple diagnoses, including COPD and heart failure, had an order for oxygen at 2 liters via nasal cannula, titrated to keep oxygen saturation above 90%. Observations found the resident receiving oxygen at 1.5 liters instead of the ordered 2 liters on two separate occasions. Staff present at the time acknowledged the incorrect setting and adjusted it to the correct flow rate. The facility's policy required that oxygen therapy be administered as prescribed and documented in the clinical record, but these requirements were not consistently met for the residents reviewed.