Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice and physician orders for two residents who required oxygen therapy. For one resident with multiple diagnoses including cerebral infarction, heart failure, and asthma, the care plan and physician order specified oxygen at 2 L/min via nasal cannula. However, repeated observations showed the resident receiving oxygen at 3 L/min, and at one point, a nurse found the oxygen set at 2.5 L/min, which was higher than the ordered amount. The nurse acknowledged the discrepancy and adjusted the oxygen flow to the correct setting. Another resident with diagnoses such as dementia, chronic respiratory failure with hypoxia, and COPD had a physician order for continuous oxygen at 3-5 L/min to maintain oxygen saturation above 90%. Observations revealed this resident was receiving oxygen at 2 L/min and 2.5 L/min at various times, which was below the ordered range. The resident was not aware of the prescribed oxygen levels and reported issues with oxygen tubing during transfers but did not mention concerns about the oxygen flow rate itself. Interviews with nursing staff and the DON confirmed that staff were expected to check and implement physician orders for oxygen therapy every shift and during transfers. The DON and nurses acknowledged that not following the prescribed oxygen settings could negatively affect residents, especially those with respiratory conditions. The facility's policy required oxygen to be administered according to physician orders and professional standards, but this was not consistently followed for the two residents identified.