Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for two residents who required oxygen therapy. For one resident with diagnoses including heart failure, morbid obesity, and COPD, the care plan required oxygen therapy at 2 liters per minute as ordered by the physician. However, multiple observations revealed that the oxygen concentrator was set above the prescribed rate, ranging from 3 to 3.5 liters per minute, contrary to the physician's order. Staff confirmed the oxygen was set higher than ordered during interviews. For another resident with morbid obesity, shortness of breath, and generalized muscle weakness, the physician's order specified oxygen at 2 liters per minute via nasal cannula as needed to maintain saturations above 92%. Observations showed the oxygen concentrator was set below the ordered rate, between 1 and 1.5 liters per minute, and staff confirmed the setting was less than 2 liters per minute. These findings were supported by photographic evidence and staff interviews, demonstrating a failure to follow physician orders for oxygen administration for both residents.