Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
Staff failed to consistently follow physician orders for oxygen administration for a resident with a history of hemiplegia, hemiparesis, spinal stenosis, major depressive disorder, and intervertebral disc disorder. The resident's care plan required the use of a BiPAP machine with 4 liters of oxygen at bedtime and during daytime naps, and the Treatment Administration Record (TAR) included orders for oxygen at 4 liters when using BiPAP. However, observations revealed that the oxygen concentrator was set below the ordered amount or was not turned on while the resident was using the BiPAP machine. On one occasion, the resident was observed asleep with the BiPAP machine in use and the oxygen concentrator set at only 1 liter. On another occasion, the concentrator was not turned on at all while the BiPAP was in use, and when it was turned on by an LPN, it was set at 1.5 liters, still below the ordered 4 liters. The DON confirmed that the oxygen concentrator should have been set at the level ordered by the physician.