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Based on interview and document review the hospital failed to adequately monitor the care of a patient requiring the use of oxygen for 1 of 3 patient records reviewed (Patient #1).

Failure to ensure a patient receives their oxygen as prescribed by the physician puts patients at risk for serious harm.

Findings included:

1. Record review of the hospital policy titled "Oxygen Therapy", revised 05/02/18 showed that titrating patients off of oxygen therapy could be done by respiratory therapists or registered nurses (RN) patients but this needed to be ordered by a physician. The respiratory therapist should communicate with the nurse managing the care of the patient when titrating oxygen therapy.

The hospital did not have a policy that instructed staff on how often a patient receiving oxygen needed to be assessed to ensure the patient was receiving the correct level of oxygen as ordered by the physician

2. Review of Patient #1's medical record showed:

a) Patient #1's physician ordered oxygen per nasal cannula at a rate of 2 liters a minute upon admission to the hospital on 03/10/19 with titration off of the oxygen to be done prn (as needed) if the patient tolerated this.

b) The patient oxygen was not in use on 03/11/19 from 8:00 AM until 8:00 PM. There was no documentation that the patient had been titrated off of the oxygen for a trial period.

3. On 11/13/19 at 10:30 AM, a licensed nurse was interviewed (Staff #1). The nurse stated that patients were assessed by the licensed nurse at the beginning of each shift and that would include ensuring the patients were receiving their oxygen as ordered. The nurse stated that there was no policy for how often the nurse was to monitor that the patient was receving their oxygen as ordered by the physician throughout the patient care shift. The nurse stated that if the respiratory therapist titrated a patient off of their oxygen this needed to be communicated to the nurse managing the care of the patient.

4. On 11/13/19 at 1:00 PM, the investigator interviewed the Chief Nursing Officer (Staff #2). Staff #2 verified the above information.