Failure to Administer Oxygen as Ordered and Lack of Required Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to physician orders for oxygen administration and by not displaying required 'oxygen in use' signage. One resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic bronchitis had a physician order for continuous oxygen at 2 L/min via nasal cannula. However, observations on multiple occasions revealed the oxygen concentrator was set at 3.5 L/min, exceeding the prescribed rate. Staff interviews confirmed that the medication aide did not check the flow rate at eye level and was unaware of the discrepancy, while the nurse had not checked the concentrator during her shift. The Medical Director confirmed that no order had been given to increase the oxygen rate and expected staff to follow the existing order. Additionally, there was no 'oxygen in use' signage on the resident's door during several observations, and the DON was unaware that such signage was required. Another resident with a history of shortness of breath and atherosclerotic heart disease had a physician order for oxygen at 2 L/min via nasal cannula to maintain oxygen saturation at 92% or above. Observations over two days showed the oxygen concentrator was set at 6 L/min, significantly higher than the ordered rate. The nurse responsible for this resident admitted she had not checked the oxygen settings on either day, despite signing the medication administration record as if the task had been completed. The Medical Director was not aware of any clinical need for the increased oxygen rate and expected staff to follow the prescribed orders and monitor oxygen saturations every shift. In both cases, the facility's staff failed to ensure that oxygen was administered at the prescribed rate and did not consistently check or document the oxygen settings as required. The lack of 'oxygen in use' signage and the failure to follow physician orders for oxygen therapy were confirmed through record reviews, direct observations, and staff interviews.