Failure to Ensure Proper Provider Orders and Administration of Oxygen
Penalty
Summary
The facility failed to ensure that proper provider orders were in place and that residents received the correct amount of oxygen as prescribed. For one resident, who had a history of chronic pain, diabetes, and dementia, observations showed that oxygen was being administered via nasal cannula at two liters per minute, but there was no provider order for oxygen in the electronic health record. Staff confirmed that the order was missing and acknowledged it was overlooked when the resident returned from the hospital. The Director of Nursing Services also confirmed that a provider's order was required for oxygen use. For another resident with diagnoses including acute and chronic respiratory failure, COPD, and heart failure, observations and interviews revealed that oxygen was being administered at six liters per minute, while the provider's order specified two liters per minute. The treatment administration record showed oxygen was used at varying rates from two to eight liters per minute. Staff confirmed that the resident was receiving six liters per minute and that the order needed clarification. The Director of Nursing Services stated that the oxygen order did not meet expectations.