Failure to Administer Oxygen Therapy as Ordered and Without Required Humidification
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of COPD, pneumonia, and acute respiratory failure with hypoxia. The resident was admitted with physician orders for oxygen at 2 liters per minute (LPM) via nasal cannula as needed to maintain oxygen saturation above 92%. However, during observation, the resident's oxygen concentrator was set at 5 LPM without a corresponding physician order, and the nasal cannula tubing was found wrapped around the bed rail rather than in use by the resident. Licensed nursing staff confirmed that the oxygen was being administered at 5 LPM, and there was no physician order for this increased flow rate. The staff also failed to provide humidification with the oxygen therapy, despite the facility's policy requiring humidification for oxygen flow rates above 4 LPM. The nurse involved stated she would need to check the order for humidification and acknowledged the importance of following physician orders for oxygen administration. Interviews with additional nursing staff and the Director of Nursing revealed that the nurse should have notified the physician about the increased oxygen flow and should have adjusted the setting to match the physician's order. The facility's policies require that oxygen and related treatments be administered as prescribed, and that humidification be used when oxygen is delivered at higher flow rates. These failures resulted in the resident receiving oxygen therapy inconsistent with both physician orders and facility policy.