Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for one patient with significant respiratory conditions. The patient, who had diagnoses including respiratory failure, COPD, pleural effusion, and was receiving palliative care, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula or mask to maintain oxygen saturation above 90%. However, record reviews showed multiple instances where the patient was documented as being on room air instead of receiving continuous oxygen. Additionally, direct observations revealed the oxygen flow was set below the prescribed rate, at 1 to 1.5 liters per minute, rather than the ordered 2 liters per minute. Interviews with facility staff, including the ADON, LVN, IPN, and DON, confirmed that the physician's order for continuous oxygen was not followed. Staff acknowledged that the patient was not consistently provided with the ordered oxygen therapy and that the oxygen flow rate was not set as prescribed. The facility's policy and procedure on oxygen administration required adherence to physician orders, but this was not maintained in the care of this patient.
Plan Of Correction
Nursing Service--Administration of Medication How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, Patient 6's oxygen setting was corrected and adjusted to 2 L/min as ordered by the physician. - On 9/24/25, the Assistant Director of Nursing (ADON) provided a one-on-one in-service to LVN #2 regarding accurate oxygen administration in accordance with physician orders. - On 9/24/25, the ADON and Director of Staff Development (DSD) conducted an in-service for Licensed Nurses, CNAs, and staff on proper oxygen administration practices per physician orders and the facility's Oxygen Policy and Procedure. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 09/24/25, the Assistant Director of Nursing (ADON) conducted rounds on all residents receiving oxygen therapy to verify that oxygen settings were consistent with current physician orders. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/15/25-10/16/25, the ADON and DSD conducted in-service training for all Licensed Nurses, Certified Nursing Assistants (CNAs), and staff on accurate oxygen administration in accordance with physician orders and the facility's Policy and Procedure on Oxygen Use. - Starting 10/13/2025, the ADON and/or DSD will conduct random rounds 3x/week for 3 months to monitor compliance with proper oxygen administration per physician orders. Any findings identified during the rounds will be addressed promptly, and reeducation will be provided as necessary. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The ADON and/or DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.