Failure to Specify Oxygen Flow Rates in Physician Orders for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen administration included specific flow rates for two residents who required respiratory care. For one resident with diagnoses including pulmonary fibrosis, COPD, acute respiratory failure, and interstitial pulmonary disease, observation revealed oxygen being administered at 6 liters per minute, but the physician's order only directed staff to maintain oxygen saturation at or above 90% without specifying a flow rate. The Director of Nursing confirmed that none of the oxygen orders for residents included flow rates, and staff would not know the correct rate without checking previous charting. A second resident, admitted with acute respiratory failure with hypoxia, heart failure, and COPD, was observed receiving oxygen via nasal cannula, with the flow rate fluctuating between 2 and 4 liters per minute as documented in the treatment record. However, the physician's order for this resident also lacked a specified flow rate, only instructing to maintain oxygen saturation at or above 90%. The DON acknowledged that the oxygen order should have included the liters per minute for administration. Facility policy requires physician orders for oxygen to include flow rate, route, and duration, but this was not followed for either resident.