Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for one resident. According to the clinical record, the resident was admitted with diagnoses including respiratory failure and congestive heart failure, and had a physician's order for continuous oxygen therapy via nasal cannula at 3 liters per minute. The resident's care plan also specified oxygen therapy at this rate, consistent with the physician's order and the facility's policy, which requires oxygen to be administered per physician instructions. Despite these orders, observations on multiple occasions showed the resident receiving oxygen at only 2 liters per minute. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident was not receiving the ordered amount of oxygen. The failure to administer oxygen at the prescribed rate constituted a violation of both the facility's policy and state regulations.