Failure to Administer Oxygen Therapy Safely and According to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not administering oxygen therapy according to the physician's orders and not following infection control protocols. Observations revealed that the resident was receiving oxygen at varying flow rates of 5 LPM and 3 LPM, while the physician's order specified oxygen at 2 LPM via nasal cannula to maintain oxygen saturation at or above 92%. Additionally, the nasal cannula in use was not labeled with an open date, contrary to facility policy, which requires nasal cannulas to be changed weekly and labeled to ensure proper infection control. Interviews with nursing staff confirmed that the oxygen flow rate was not set according to the doctor's order and that the nasal cannula lacked the required date label. The staff acknowledged that licensed nurses are responsible for setting oxygen as prescribed and for labeling and changing nasal cannulas as per policy. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and cognitive impairment, requiring supervision and assistance with daily activities. The facility's policy and procedure on oxygen therapy emphasized the need for safe administration and proper labeling of equipment, which was not followed in this instance.