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Based on interview, record review and a review of facility documentation, the facility failed to ensure that oxygen therapy services were provided under orders which included guidance or specific directives concerning the amount of oxygen to be delivered for 1 of 5 sampled patients (#4).

Findings:

Patient #4's medical record reflected the following. The patient was admitted to the hospital on 7/26/21. On 7/26/21, the physician ordered "Oxygen Therapy Device: Nasal Cannula." However, there were no corresponding orders for the amount of oxygen to be given to the patient, such as titration or maintenance of O2 (oxygen) above a certain level of oxygen saturation (SPO2). The record revealed placement of a nasal cannula at 2 Liters per minute on 7/26/21 at 6:24 AM. The record revealed continued use of the nasal cannula for oxygen delivery throughout the patient's stay. The first notation regarding oxygen delivery after this order was on 7/26/21 at 6:24 AM. It indicated that the patient was on a nasal cannula at 2 liters per minute. The last notation concerning the nasal cannula was on 8/01/21 at 3 AM. It indicated that the patient was on a high flow nasal canula at 55 Liters per minute.

The hospital's "Oxygen Therapy" policy read, "It is the policy....that oxygen therapy shall be administered and maintained: Upon physician's order or by appropriate established protocol. Orders shall include: (1) Specific delivery device, liter flow or concentration, or (2) Oxygen Therapy Protocol when no delivery device is specified, or when no SPO2 or PAO2 [partial pressure of oxygen] parameters are specified." Regarding patient #4, item (2) required the use of an Oxygen Therapy Protocol when no SPO2 or PAO2 parameters are specified. There was no evidence in the medical record of any SPO2 or PAO2 parameters being specified, and there was no evidence of an Oxygen Therapy Protocol being ordered. The patient was given oxygen in amounts which had not been authorized by a physician.

During an interview of the Risk Manager on 9/24/21 at approximately 10:30 AM, she confirmed the finding.