Failure to Reconcile and Update Oxygen Therapy Orders After Hospital Discharge
Penalty
Summary
The facility failed to accurately reconcile and update physician orders for a resident receiving oxygen therapy following a hospital discharge. Despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night, the electronic medical record, care plan, and medication administration record (MAR) continued to reflect the previous order of 2 L/min at rest and overnight. Multiple observations showed the resident receiving oxygen at 3 L/min from both the concentrator and portable tank, which did not match either the old or new physician orders. Staff did not verify or adjust the flow rate according to the updated order, and there was no documentation that the MAR had been reconciled with the most recent physician instructions. Interviews revealed that direct care staff were not permitted to change the oxygen flow rate and only switched the tubing between devices. The registered nurse was unaware of the updated order and did not verify the MAR against the new physician order. The administrator also confirmed that the order summary report had not been updated to reflect the change. Additionally, the facility lacked a policy for reconciling physician orders, and the existing oxygen administration policy did not address documentation of the amount of oxygen administered. The resident's oxygen saturation levels were monitored, but there was no evidence that staff checked or documented the actual flow rate as required by the updated physician order.