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Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient 1) received the oxygen therapy as per the physician's plan. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

On 8/13/24, Patient 1's closed medical record was reviewed. Patient 1's medical record showed Patient 1 was admitted to the hospital on 1/13/24, and discharged on 1/23/24.

Review of the physician's order dated 1/15/24 at 1312 hours, showed to administer oxygen via nasal cannula and titrate FiO2 to keep SpO2 > 88%.

Review of the Pulmonary Critical Care Consultation dated 1/19/24 at 1307 hours, showed the following:

* The pulmonary critical care was consulted for the developed chronic hypercapnia and altered mental status.

* The Blood Gas section showed the patient's pCO 2 was 36.3 mmHg (normal pCO2 in the blood is between 35 to 45 mmHg) on 1/14/24 at 1148 hours, 72.6 mmHg on 1/18/24 at 1455 hours, and 64.2 mmHg on 1/19/24 at 0421 hours.

* The Plan section showed to continue supplemental oxygen, titrate to keep SpO2 between 89- 92%, and avoid excess oxygenation.

Review of the Pulmonary Disease Progress Note dated 1/22/24 at 1718 hours and 1/23/24 at 2030 hours, showed the same plan as 1/19/24 at 1307 hours.

Review of Patient 1's SpO2 from 1/19/24 at 1500 hours to 1/23/24 at 1928 hours, showed Patient 1's SpO2 was either equal or greater than 92 %.

On 8/13/24 at 1401 hours, the CNO was interviewed. When asked, the CNO stated a physician placed an order so the nurses or other disciplinary department staff could follow the plan and orders.

Further review of Patient 1's medical record showed there was no physician's order to carry out the physician's plan to keep the patient's SpO2 between 89 - 92 % and avoid excess oxygenation.

On 8/13/24 at 1510 hours, the CNO and Director of Performance Improvement verified the above findings.