Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and congestive heart failure was admitted to the facility and required continuous oxygen therapy as indicated in their Minimum Data Set assessment. The physician's order specified that the resident should receive oxygen at eight liters per minute via a re-breathable mask to maintain oxygen saturation at 92% or above. However, during an observation, the resident was found to be receiving only three liters per minute of oxygen via a nasal cannula, which did not match the physician's order. Interviews with the LVN responsible for the resident's care revealed that she had not checked the physician's order and was unaware of the correct oxygen administration method and flow rate. The Director of Nursing confirmed that all licensed staff are responsible for following physician orders and that failure to do so could result in inadequate care. Review of facility policy and the LVN job description further emphasized the requirement to check physician orders and administer treatments as prescribed.