Failure to Follow Physician Orders for Oxygen Therapy and Inadequate Response to Change in Condition
Penalty
Summary
Surveyor observations, medical record reviews, and staff interviews revealed that the facility failed to follow physician orders for oxygen therapy for two residents. One resident was observed receiving oxygen at 3.5 liters per minute (LPM) when the physician's order specified 2 LPM, and another was receiving 2.5 LPM instead of the ordered 2 LPM. Nursing staff were unaware of the correct flow rates and reported checking oxygen flow meters only weekly or every other day, rather than every shift as required by the orders. Staff were unable to state when the oxygen flow rates were last checked, and adjustments were only made after surveyor intervention. Additionally, the facility failed to appropriately assess and report a change in condition for a resident with multiple complex medical issues, including end-stage renal disease, diabetes, and a sacral pressure ulcer. The resident reported vomiting multiple times, but there was no evidence of a thorough assessment or notification to a practitioner at that time. Later, when the resident was found lethargic, the nurse did not obtain vital signs or a blood sugar level before sending the resident to the hospital. Documentation of the change in condition was incomplete, and the nurse did not fully assess the resident prior to transfer. Interviews with facility staff confirmed that the expected protocols for monitoring oxygen therapy and responding to changes in resident condition were not followed. The DON acknowledged that nurses would not have known the correct oxygen flow rates if checks were only performed weekly, and the unit manager stated that a full assessment and practitioner notification should have occurred for the resident with vomiting and lethargy. The nurse involved in the change in condition incident was an agency nurse and was unavailable for interview.