Failure to Provide Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders and facility policy for two residents requiring oxygen therapy. For one resident with chronic respiratory failure and muscle weakness, the physician's order specified that oxygen tubing should be changed and dated weekly on the night shift every Thursday. However, observation revealed that the nasal cannula was not dated, and the humidifier solution cannister attached to the oxygen concentrator was last dated nearly two weeks prior. An LPN confirmed these findings during the observation. For another resident with chronic obstructive pulmonary disease, asthma, and hypertension, the physician's order required oxygen to be administered at three liters per minute via nasal cannula to maintain oxygen saturation above 90%. Multiple observations showed the resident receiving supplemental oxygen at only two liters per minute, which was not in accordance with the physician's order. An LPN confirmed that the oxygen flow rate was set incorrectly. These failures were identified through review of clinical records, direct observation, and staff interviews.