Failure to Ensure Physician Orders and Correct Administration of Oxygen
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not following physician orders and lacking required documentation. One resident with a history of congestive heart failure and dementia was observed using oxygen without a physician's order. Documentation and staff interviews confirmed that the resident had been using oxygen intermittently for at least a week, including nightly use, without an order in place. The facility's policy allows for emergency administration of oxygen in cases of respiratory distress, but requires that a physician's order be obtained as soon as practicable, which was not done for this resident. Another resident with chronic obstructive pulmonary disease (COPD) and an order for continuous oxygen at three liters per minute was observed receiving oxygen at five liters per minute on multiple occasions. Staff confirmed the oxygen was set above the ordered rate and acknowledged the discrepancy. These findings demonstrate that the facility did not ensure oxygen was administered as ordered by the physician and failed to obtain necessary orders for oxygen administration when initiated.