Oxygen Therapy Administered Above Ordered Flow Rate
Penalty
Summary
A deficiency occurred when a resident was observed receiving oxygen therapy at a rate of 5 liters per minute (LPM) via nasal cannula, despite a physician's order specifying oxygen administration at 3 LPM continuously to maintain oxygen saturation above 92%. Multiple observations confirmed the oxygen concentrator was set at 5 LPM, and this was acknowledged by a registered nurse who stated the order was for 3 LPM and the setting should not have been at 5 LPM. The Director of Nursing also confirmed that nurses are expected to follow the physician's order for oxygen administration. Review of the facility's policies indicated that staff are required to verify physician orders for oxygen therapy, adjust the flow rate as ordered, and document the flow rate, duration, and patient response. The failure to administer oxygen at the prescribed rate was not in accordance with these policies and procedures, and this discrepancy was identified through observation, interview, and record review.