Failure to Follow and Accurately Document Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not following the active medical order for continuous oxygen therapy. The resident was observed receiving oxygen at 5 liters per minute via nasal cannula, despite an active medical order specifying continuous oxygen at 4 liters per minute. This discrepancy was confirmed by both the unit manager and the Director of Nursing during the survey. Additionally, the resident's care plan contained conflicting interventions, listing both 4 liters and 3 liters of oxygen via nasal cannula, and a progress note from a nurse practitioner documented the resident as being on oxygen as needed at 3 liters, which did not match the active order. The lack of consistency between the physician's orders, the care plan, and the actual care provided resulted in the resident not receiving respiratory care as prescribed. The surveyor's review found that the resident's care plan and medical record did not accurately reflect the current medical order for oxygen therapy, and the care provided did not align with the physician's instructions. These findings were acknowledged by facility leadership during the survey.