Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care consistent with professional standards of practice for a resident receiving oxygen therapy. Observations revealed that the resident, who had severe cognitive impairment and was dependent on ADLs, was receiving oxygen at 1.25 liters per minute via nasal cannula, despite a physician's order for 2 liters per minute. This discrepancy was observed on two separate occasions, and photographic evidence was obtained. The resident's care plan and physician's orders both specified the need for continuous oxygen at 2 liters per minute, but staff did not ensure the prescribed rate was being delivered. A registered nurse acknowledged not verifying the oxygen flow rate during morning rounds. The resident had a history of acute chronic diastolic congestive heart failure, nonrheumatic aortic valve stenosis, and was receiving hospice care. During the survey, the resident's oxygen saturation was found to be critically low at 76% while on the incorrect oxygen flow rate. The facility's policy required staff to set the oxygen concentrator to the prescribed flow rate, but this was not followed, resulting in the resident receiving less oxygen than ordered.