Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. The resident, who was cognitively intact and had diagnoses of chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at a flow rate of 3.5 liters per minute instead of the prescribed 3.0 liters per minute. This discrepancy was noted during multiple observations over two days. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse Supervisor, confirmed the incorrect oxygen flow rate. The LPN suggested that the resident might have adjusted the oxygen flow rate herself, although this was not documented in the resident's care plan. The Director of Nursing also confirmed the discrepancy and acknowledged that the oxygen should have been set at 3 liters per minute as per the physician's order.
Plan Of Correction
1. The physician order for R29 was immediately corrected. 2. The Director of Nursing or designee will audit current physician oxygen orders to ensure oxygen is administered in accordance with the physician order. 3. The Director of Nursing or designee will re-educate nursing staff on the procedure that oxygen is administered in accordance with the physician order and documented on the medication administration record. 4. The Director of Nursing or designee will audit 25% of residents with oxygen physician orders and that the correct oxygen rate is administered. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.