Failure to Obtain CPAP Settings and Follow Oxygen Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not obtaining required physician orders for CPAP settings and not following a physician's order for oxygen administration. For one resident with a history of chronic respiratory failure and chronic obstructive pulmonary disease, there was no documented physician order specifying the oxygen concentration, flow, or pressure settings for CPAP administration, as required by facility policy. The Quality Improvement Nurse confirmed the absence of these necessary orders. For another resident, staff did not adhere to the physician's order for oxygen administration at 2 liters per minute (LPM) via nasal cannula. Observations showed that the resident was receiving oxygen at 3 LPM, and the nasal cannula was not properly positioned over both nares. Both the Assistant Director of Nursing and a Licensed Practical Nurse confirmed that the oxygen was not set according to the physician's order.