Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, asthma, and dysphagia did not receive oxygen therapy in accordance with the physician's order. The resident was ordered to receive continuous oxygen at three liters per minute via nasal cannula, with the care plan specifying that the oxygen flow should be checked every four hours. However, during an observation, the resident was found to be receiving four liters per minute. The attending LVN confirmed the discrepancy and adjusted the oxygen flow to the ordered amount. Record reviews showed that documentation indicated the resident was receiving the correct amount of oxygen and that checks were being performed as required, but direct observation contradicted this. Interviews with nursing staff and the DON confirmed that oxygen administration should follow the physician's order and that only licensed nurses are permitted to adjust oxygen levels. Facility policies also required staff to verify and set oxygen delivery to the prescribed flow rate.