Failure to Provide Oxygen Therapy per Physician's Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to physician's orders for a resident with respiratory failure, COPD, and hypertension. The physician's orders specified oxygen at two liters per minute as needed via nasal cannula, with instructions to change the oxygen tubing and supply bag weekly, wipe down the concentrator and clean the filter weekly, and change the water jug weekly. Over a period of several days, observations revealed that the resident was receiving oxygen at one and a half liters per minute, which was not in accordance with the prescribed flow rate. Additionally, the oxygen concentrator was missing both the water bottle and the external filter, contrary to facility policy and physician's orders. Repeated observations confirmed that the deficiencies persisted over multiple days, with the resident consistently receiving oxygen at the incorrect flow rate and without the required water bottle and filter attached to the concentrator. The DON confirmed during an interview that the oxygen was not set per the physician's order and that the necessary equipment was missing. These findings were based on review of facility policy, clinical records, direct observation, and staff interview.