Failure to Follow Physician Orders for Oxygen Supply Changes
Penalty
Summary
The facility failed to follow physician orders regarding the timely changing of oxygen supplies for a resident with chronic obstructive pulmonary disease (COPD) who required supplemental oxygen. The resident's care plan included interventions to administer oxygen as ordered, and a physician order specified that the nasal cannula tubing and humidifier bottles were to be changed every seven days when oxygen was in use, specifically on the night shift every Wednesday. Documentation in the Medication Administration Record indicated that the oxygen nasal cannula was marked as changed on two occasions; however, direct observation revealed that the cannula in use was dated from a previous period, indicating it had not been changed as required. Interviews with nursing staff and the Director of Nursing confirmed that the responsibility for changing the oxygen supplies fell to the night nurse assigned to the resident. One nurse admitted to signing off on the task as completed before actually performing the change and acknowledged that it may have slipped his mind. The DON and Administrator both confirmed that the assigned nurse was responsible for ensuring the physician's order was carried out, but the order was not followed as documented and observed.