Failure to Ensure Physician Orders and Accurate Administration of Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not having a current physician's order for oxygen administration and by not following the prescribed oxygen flow rates. One long-term resident was observed receiving oxygen via nasal cannula at 2L/min without a corresponding physician's order in place. Review of the resident's records showed that the previous oxygen order had been discontinued upon hospital transfer, and no new order was documented upon the resident's return to the facility. Additionally, there was no documentation of oxygen administration in the medication administration record for several weeks, despite evidence from vital signs and nursing assessments that the resident was receiving oxygen during that period. Another resident was observed receiving oxygen at a rate of 3.5L/min, while the physician's order specified 2L/min. The resident was aware of the prescribed rate, but the oxygen concentrator was set higher than ordered. This discrepancy was confirmed by an LPN during the survey. In both cases, the facility did not ensure that oxygen therapy was administered according to physician orders, nor did it maintain accurate documentation of the care provided.