Failure to Follow Oxygen Orders and Document Respiratory Status Change
Penalty
Summary
The deficiency involves staff failing to follow a physician’s order for oxygen therapy and failing to document a change in respiratory care for one resident. The resident had chronic respiratory failure with hypoxia, COPD, and a tracheostomy, and had a physician’s order for an oxygen concentrator set at 3 LPM on all shifts. During observation, the resident’s oxygen concentrator was found set at 4 LPM, and the resident reported that staff had increased the flow from 3 LPM to 4 LPM a couple of days earlier when his oxygen saturation was 72%. A subsequent observation again confirmed the concentrator remained at 4 LPM. Record review showed no documentation of when the oxygen flow was increased, no respiratory assessment to support the change, and no evidence that the provider was notified or that new orders were obtained. An LPN confirmed the discrepancy between the ordered 3 LPM and the observed 4 LPM setting and acknowledged there was no documentation explaining the change or provider notification. The DON stated that staff were expected to document an assessment, notify the provider and family, and obtain new orders when a resident’s respiratory status changed and oxygen concentration was adjusted, but confirmed that none of this was documented for this resident, and there were no messages in the communication application regarding a change in respiratory status or the need to increase oxygen concentration.
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