Failure to Follow Physician Orders for Oxygen and Enteral Feeding
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with dementia and COPD, the facility did not have a physician's order specifying the amount of oxygen to be administered via nasal cannula, nor instructions on how often the oxygen tubing should be changed. Observations showed the resident consistently using oxygen at 4 liters with unlabeled and undated tubing, and both the ADON and DON confirmed the absence of a required physician's order and related care plan documentation. For another resident with respiratory failure, gastrostomy, tracheostomy, and quadriplegia, the facility did not implement the physician's order for enteral feeding. The resident was observed receiving a different formula and rate (Jevity 1.2 cal at 58 ml/hr) than what was ordered (Jevity 1.5 cal at 55 ml/hr). Nursing staff were unaware of the discrepancy until it was pointed out, and the DON confirmed that physician's orders should be followed as written.