Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care, including oxygen therapy, did not receive care consistent with physician orders and professional standards. The resident, an elderly male with multiple diagnoses including COPD, vascular dementia, and recent pneumonia, was readmitted to the facility with hospital discharge instructions to continue oxygen at 3 L/min via nasal cannula for comfort. However, upon return, nursing staff administered oxygen at 2 L/min instead of the ordered 3 L/min, without verifying the current physician order. The LPN responsible for the resident's care assumed the 2 L/min setting was correct because that was the level upon the resident's arrival and did not check the physician's order. The LPN also did not document the resident's vital signs in the electronic record, instead recording them in a personal notebook. The resident's oxygen saturation was noted to be 92% while on 2 L/min, but the LPN did not consider this a concern and did not consult the physician or review the written orders. The facility's policy required verification of physician orders prior to oxygen administration, but this step was omitted. Interviews with facility leadership confirmed that staff were expected to review and verify orders upon a resident's return from the hospital. The ADON and ADM both stated that orders should be checked to ensure residents receive care as directed by the physician. The failure to verify and follow the correct oxygen order resulted in the resident receiving a lower oxygen flow rate than prescribed, contrary to both facility policy and professional standards of practice.