Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with the physician's order for one resident diagnosed with chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. The resident's clinical record included a physician's order for oxygen administration via nasal cannula at 2 liters per minute (LPM) during the day shift, to be used when oxygen saturation dropped or the resident was unable to breathe. Documentation in the electronic medication administration record indicated that oxygen was administered as ordered each day. However, during surveyor observations on two separate occasions, the resident was found receiving oxygen at 5 LPM, not the 2 LPM specified in the physician's order at that time. The resident confirmed that the oxygen was supposed to be at 5 LPM, but the clinical record and orders had not been updated to reflect this until after the surveyor's inquiry. The facility's policy required verification and documentation of the physician's order and the oxygen flow rate, but this was not followed prior to the order being changed.