Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, heart failure, and a history of stroke, was not provided respiratory care in accordance with physician orders. The resident was ordered to receive continuous oxygen at 2 liters per minute via nasal cannula, with staff responsible for monitoring and maintaining this level each shift. However, observations on multiple occasions revealed the resident was receiving oxygen at 3 liters per minute. The resident confirmed she was supposed to be on 2 liters and was unaware of any change to 3 liters. Nursing staff, including an LVN, also confirmed the order was for 2 liters and could not identify who had increased the oxygen flow or when the change occurred. The LVN acknowledged that any change in oxygen delivery should be communicated to and ordered by a physician, and that staff were responsible for monitoring and documenting oxygen levels each shift. The DON stated that staff should check the resident's oxygen level, tubing, and water each shift, and that any changes to oxygen flow should be documented and ordered by a physician. The DON also noted that the resident or family members sometimes changed the oxygen level, necessitating staff education to prevent unauthorized adjustments. Review of facility policy confirmed that licensed nursing staff are required to provide treatments as ordered by the physician. The failure to ensure the resident received oxygen therapy as ordered, and to monitor and document changes, resulted in a deficiency related to the provision of safe and appropriate respiratory care.