Failure to Follow Orders for Oxygen Therapy and CPAP Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for oxygen therapy and CPAP use for a resident with significant respiratory and cardiac conditions. The resident had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, congestive heart failure, chronic kidney disease, and dysphagia, and required continuous oxygen per the care plan at 2 L/min via nasal cannula. The care plan also included interventions such as educating the resident on keeping oxygen on at the prescribed setting, maintaining the head of bed elevated, and reporting signs of hypoxia. However, documentation and orders were inconsistent with the NP’s stated intent that oxygen should be used on an as-needed basis to maintain oxygen saturation above 90%, not as continuous oxygen. Pulmonology after-visit documentation indicated the resident had OSA and was to resume CPAP at 15 cm H2O when available, noting the resident had been more short of breath at night while not on oxygen and that the CPAP machine had malfunctioned and a new machine had been ordered months earlier. Despite this, there were no physician orders in the record from November through February for CPAP at 15 cm H2O, and the resident was not using CPAP as ordered by the pulmonologist. The resident reported not using the CPAP because the mask was broken, although a new mask was later obtained, and the DON confirmed the resident had a CPAP machine but the face mask was broken and being replaced. The DON also stated the resident frequently refused CPAP, but there was no documentation of refusals in the record. NP progress notes on multiple dates documented that the resident should wear CPAP at night and with naps, and that staff should monitor oxygen saturation and provide oxygen at 2 L/min as needed to keep saturation above 90%. The NP stated that staff sometimes requested oxygen for the resident and she would give verbal orders for PRN oxygen at 2 L/min for shortness of breath or oxygen saturation below 90%. However, review of physician orders for December, January, and February showed only an order for continuous oxygen at 2 L/min and no PRN oxygen order matching the NP’s plan. Both the DON and NP were unsure of the origin of the continuous oxygen order dated in late November, and the facility’s own policies required verification of a physician order for oxygen administration and outlined procedures for CPAP/BiPAP support that were not reflected in the documented orders and implementation for this resident.
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