Failure to Update Oxygen Orders for Resident with Increased Oxygen Needs
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, and hypoxia was admitted with a physician's order to titrate supplemental oxygen between 1 to 5 liters per minute (L/min) to maintain oxygen saturation between 88% and 92%. Record reviews showed that on multiple occasions, the resident received oxygen at a flow rate of 6 L/min, which exceeded the prescribed range. Documentation did not indicate that the physician's order was updated to reflect the increased oxygen requirement. Interviews with facility staff, including the DON and Administrator, confirmed that the resident was administered oxygen above the ordered range and that the physician should have been notified to update the order. There was no documentation to show that the provider was informed when the resident's oxygen needs exceeded the prescribed parameters. The Medical Director also stated that orders should be followed as written.