Failure to Follow Physician Orders and Provide Safe Oxygen Therapy
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care and services regarding oxygen therapy for three residents. For one resident with acute and chronic respiratory failure, COPD, and dependence on supplemental oxygen, observations on multiple occasions revealed the resident was lying in bed with the head of bed (HOB) flat, despite physician orders and care plan directives to keep the HOB elevated to promote oxygenation and prevent shortness of breath. Both nursing staff and the Director of Nursing confirmed the HOB should have been elevated as ordered. Two other residents were observed receiving oxygen therapy via binasal cannula at various flow rates, but neither had a physician's order, care plan documentation, or medication administration record indicating oxygen therapy was prescribed. Nursing staff confirmed the absence of orders for oxygen therapy for these residents, and the DON acknowledged that a physician's order is required for oxygen administration. These findings were based on policy review, medical record review, direct observation, and staff interviews.