Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of acute respiratory failure with hypoxia did not receive oxygen therapy according to physician orders. The physician's order specified oxygen at 2 liters per minute (LPM) via nasal cannula continuously and required the oxygen tubing to be changed weekly on Wednesdays. However, observations revealed that the resident was receiving oxygen at 3 LPM, and the oxygen tubing in use was dated nearly two weeks prior, indicating it had not been changed as ordered. Documentation in the Treatment Administration Record confirmed that nursing staff recorded the resident as being on 2 LPM, but direct observation contradicted this, showing the oxygen set at 3 LPM. During interviews, an LPN acknowledged the discrepancy in both the oxygen flow rate and the tubing change schedule, stating tubing was changed every three days rather than weekly. The DON confirmed that staff were expected to check oxygen settings every shift and change tubing weekly, but these practices were not followed for this resident.