Failure to Follow Physician's Order for Supplemental Oxygen Administration
Penalty
Summary
The facility failed to follow a physician's order for the administration of supplemental oxygen for one resident with a history of heart failure, pulmonary hypertension, chronic obstructive pulmonary disease, diabetes, and generalized weakness. The resident was admitted with an order for supplemental oxygen at 2 liters per minute (LPM) via nasal cannula every shift. However, during observation, the oxygen concentrator was set at 3 LPM. Interviews with nursing staff confirmed that the oxygen was not set according to the physician's order, and staff were unable to explain why the flow rate was incorrect. The resident reported not adjusting the oxygen flow rate and was unaware of how to do so. Further interviews revealed that the facility did not have a policy for oxygen administration, although the staff development coordinator stated that oxygen administration and flow rate adjustment were included in nurse competencies. The DON and medical director both stated that nurses were expected to check and document the oxygen flow rate every shift and follow physician orders, with any changes requiring a new order. The administrator confirmed that nurses were expected to follow physician orders for oxygen administration and had not received reports of the resident adjusting the flow rate.