Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders regarding oxygen therapy. One resident was observed lying in bed with the oxygen concentrator set to 2 liters per minute (lpm), but the nasal cannula tubing was not applied and was instead wrapped around the bed rail with the nasal prong on the floor. The resident was not in distress at the time, but the oxygen was not being delivered as ordered. A Certified Nursing Assistant later applied the nasal cannula and acknowledged it should have been in place. Another resident was found receiving oxygen via nasal cannula at a flow rate of 3 lpm, despite a physician's order for continuous oxygen at 2 lpm. This discrepancy was confirmed by both an agency LPN and a Registered Nurse, who verified the order and the incorrect setting. The Director of Nursing stated that oxygen administration must follow the physician's order, as it is considered a medication. Both residents had significant medical histories, including chronic respiratory conditions and cognitive impairments, and required staff assistance for mobility and care.