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Based on observation, record review, and interview, the facility staff failed to administer oxygen per physician orders for 1 of 5 patients observed (Patient #6) on the Cardiac Care Unit, in a total sample of 8 patient observations.

Findings include:
Record review of facility policy "Assessment/Reassessment of Patients, an Interdisciplinary Approach" ID 12003137 revealed "Each discipline documents their interventions and the patient's response to these interventions. ...As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patient's needs are met."

During an observation of Patient #6 at 1:55 PM on 10/17/22, Patient #6's oxygen tubing was not connected to the wall oxygen, the nasal cannula was not on Patient #6, and the oxygen tubing was lying next to Patient #6 in bed. Patient #6 did not have pulse oximetry reader on his finger.

During an interview with Patient #6 at 1:55 PM on 10/17/22 he stated, "I would like help getting my breathing tube back on."

Record review of Patient #6's medical record revealed Patient #6 was admitted 10/12/22 with necrotizing fasciitis (flesh-eating disease) left foot, renal failure, anemia (low red blood cell counts) and chronic lymphocytic leukemia.

Patient #6's orders included a physician order to "titrate O2 [oxygen] to maintain oxygen saturation greater than 92%." Patient #6's oxygen flowsheet dated 10/17/22 at 7:00 AM revealed Patient #6's oxygen saturation was 75% on room air. There were no additional vital signs documented for over 8 hours, from 7:00 AM until the time of review at 3:30 PM on 10/17/22.

During an interview on 10/17/22 at 4:00 PM, Registered Nurse (RN) I stated she was aware of Patient #6's O2 saturation of 75% on room air. When asked if any interventions were done in response, such as administer oxygen as ordered, RN I stated "The pulse oximetry reader was not picking up his oxygen saturation due to his cold extremities. It can switch from having a good oxygen reading to not reading the oxygen saturation." When asked if Patient #6's oxygen saturation was reassessed after the reading of 75% at 7:00 AM, RN I stated "we are supposed to check patient's vital signs every four hours." RN I stated she did not obtain an oxygenation saturation rate of 92% and confirmed she did not administer O2 to Patient #6.

On 10/17/22 at 4:40 PM during interview with Quality Manager C, when asked if the registered nurse is expected to follow the physician order for Patient #6 to titrate his/her O2, C stated there is no policy to address this, but confirmed, "yes" the expectation is to follow the physicians orders.