Incomplete Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders for oxygen administration were complete and accurate for three residents who were receiving oxygen therapy. In each case, the physician's order specified the need to titrate oxygen to maintain a certain oxygen saturation level but did not specify the required liter flow rate. Observations confirmed that residents were receiving oxygen at various flow rates, but staff were unable to verify if these rates matched the physician's intent due to the incomplete orders. Interviews with nursing staff confirmed that they were not aware of the specific oxygen flow rates that should have been administered, making it impossible to monitor or ensure the accuracy of oxygen therapy. The affected residents had diagnoses including hypoxia, dementia, diabetes, chronic obstructive pulmonary disease, obstructive sleep apnea, Barrett's esophagus, cognitive deficit after cerebral infarct, and hypothyroidism. At the time of observation, all residents were receiving oxygen via nasal cannula and were not in distress. Facility policy required that oxygen be administered under a physician's order consistent with professional standards, but the lack of specified flow rates in the orders resulted in non-compliance with this policy.