Failure to Obtain Orders and Administer Oxygen Therapy per Physician Instructions
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for one resident and did not administer oxygen according to physician orders for another. One resident with multiple respiratory and cardiac diagnoses was observed receiving oxygen therapy via nasal cannula at a rate of two and one half liters per minute, but there was no physician order specifying the oxygen therapy, rate, or delivery method. The same resident's oxygen humidifier bottle was found to be completely dry on two separate occasions, and both the humidifier bottle and nasal cannula tubing had not been changed as scheduled per the physician order sheet. The resident reported that the humidifier bottle was frequently dry and that no one had replaced it as required. Another resident with emphysema, sleep apnea, and a pulmonary nodule was observed receiving oxygen at five liters per minute, despite a physician order specifying two liters per minute at night, during naps, and as needed during the day. The humidifier bottle for this resident contained only a minimal amount of water, insufficient for proper humidification, and neither the bottle nor the tubing was dated to indicate when they were last changed. The DON confirmed that the humidifier bottle should have been changed the previous night according to orders, and the facility's policy requires verification of physician orders, proper equipment setup, and regular checks of water levels in humidifier bottles.