Failure to Follow Physician's Oxygen Order and Monitor Resident's Oxygen Use
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen administration for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's care plan required oxygen to be administered at 2 liters per minute (l/m) via nasal cannula as needed for oxygen saturations below 88%. However, observations revealed the oxygen concentrator was set at 3 l/m, exceeding the ordered flow rate. Additionally, the resident was observed multiple times without the nasal cannula in place, despite the oxygen concentrator running, and staff did not intervene to ensure the resident was receiving oxygen as ordered. Further review showed that the resident's oxygen saturation dropped to 83% while off oxygen, and only after this was noted did a nurse place the nasal cannula on the resident and adjust the flow rate. The failure to ensure the resident received oxygen at the prescribed rate and to monitor the resident's oxygen use as ordered resulted in the resident not receiving appropriate respiratory care according to physician orders and facility policy.