Failure to Obtain and Follow Accurate Oxygen Orders for Resident
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for one resident who required oxygen therapy. The facility's policy required that oxygen be administered only with a physician's order, and that the order should specify the method and flow rate. Review of the resident's physician orders showed an order for oxygen via mask at 3-4 liters per minute (LPM) continuously. However, multiple observations revealed that the resident was receiving six LPM of oxygen via nasal cannula, which did not match the physician's order on record at the time. Interviews with nursing staff and record reviews confirmed that the resident's oxygen delivery method and flow rate had changed due to a change in condition, but the physician's order was not updated to reflect this change until several days later. Staff acknowledged that the order should have been clarified and updated to match the resident's current needs, and that the resident was receiving a higher flow rate and a different delivery method than what was ordered. This discrepancy between the physician's order and the care provided constituted a failure to follow professional standards and facility policy for respiratory care.