Failure to Follow and Update Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the correct physician order for oxygen therapy was followed and appropriately monitored for a resident with a history of acute respiratory failure and hypoxia. The resident was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite the most recent physician order specifying 1-2 L/min during the day and 2 L/min at night. The care plan and medication administration record (MAR) were not updated to reflect the new order, and staff continued to document and administer oxygen based on outdated instructions. Additionally, there was no evidence that staff were verifying the actual flow rate or reconciling the MAR with the current physician order. Direct care staff were observed switching the resident between an oxygen concentrator and a portable tank, both set at incorrect flow rates. Interviews revealed that staff were unaware of the updated order and did not verify the accuracy of the MAR. There was also no documentation that the resident's family, who may have adjusted the oxygen flow, had been educated not to do so. The facility's oxygen administration policy did not specify procedures for documenting the amount of oxygen administered, contributing to the lack of oversight and consistency in care.