Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a physician's order for oxygen administration for a resident with acute respiratory failure, congestive heart failure, anemia, and shortness of breath. The resident was ordered to receive oxygen at 2 liters per minute (LPM) continuously via nasal cannula. However, observations revealed that the oxygen concentrator was set at higher levels, specifically 4 LPM and 3.5 LPM, during different times. This discrepancy was confirmed by both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged the incorrect settings and adjusted the concentrator to the correct level. The LPN responsible for the resident's care indicated that her duties included checking the oxygen concentrator settings when administering medications and ensuring the nasal cannula was properly placed. Despite these responsibilities, the oxygen was not set according to the physician's order. The DON confirmed the expectation that nurses should verify the oxygen settings at the start of their shifts and periodically thereafter. The facility's policy on oxygen administration mandates that oxygen be administered as ordered by the physician, which was not followed in this instance.