Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypoxia and congestive heart failure did not receive respiratory care in accordance with the physician's order. The resident was observed using oxygen at a flow rate of four liters per minute (LPM) via nasal cannula, despite the physician's order specifying two LPM continuously and as needed. The resident was also observed turning off the oxygen concentrator due to frequent alarms and was unsure of the correct oxygen flow rate. On a subsequent observation, the oxygen concentrator was found turned off and the nasal cannula was not in use, with the resident stating she had turned it off due to noise. Nursing staff confirmed that the resident had a habit of turning the machine on and off and resetting it herself, and acknowledged that the oxygen flow rate was set incorrectly at four LPM instead of the ordered two LPM. Staff also indicated that it was their responsibility to check the oxygen flow rate and ensure compliance with the physician's order, but this was not consistently done. Record review showed inconsistencies in the documentation of oxygen administration, with the physician's order ambiguously stating both continuous and as-needed use, and the care plan requiring monitoring of oxygen saturation and administration at a specified rate. The facility's policy required verification of physician orders, review of care plans, and documentation of oxygen flow rate, route, and rationale, as well as assessment of oxygen use each shift. However, these procedures were not followed, resulting in the resident not receiving oxygen therapy as ordered and staff failing to ensure the correct oxygen flow rate and usage.