Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for oxygen therapy for two residents. For one resident with heart failure, COPD, and asthma, observations showed oxygen was administered at five and six liters per minute via nasal cannula, while the provider order specified three liters per minute continuously. Documentation in the treatment administration record indicated the order was being followed, but interviews with staff confirmed the resident was receiving a higher oxygen flow than ordered, and there was no documentation of a provider order change or notification. For another resident with encephalopathy, diabetes, and dementia, observations on multiple occasions showed oxygen was set at three liters per minute via nasal cannula, while the care plan required one liter continuously. Staff interviews confirmed the oxygen was set higher than ordered, and the expectation was that staff follow provider orders and monitor oxygen settings every shift. These failures resulted in oxygen being administered at rates inconsistent with physician orders for both residents.