Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy in accordance with physician orders for two residents with severe cognitive impairment and significant respiratory diagnoses. For one resident with COPD, pulmonary fibrosis, and dyspnea, the physician ordered oxygen via nasal cannula at 3 liters per minute (LPM). However, multiple observations showed the resident receiving oxygen at 4 to 4.5 LPM. The resident's care plan specified oxygen therapy during meals as ordered, and the Director of Nursing confirmed that the resident could not adjust the flow meter independently. Staff interviews indicated that oxygen should be administered per physician orders, and photographic evidence confirmed the incorrect flow rate. For another resident with a diagnosis of malignant neoplasm of the lung, the physician ordered oxygen at 2 LPM via nasal cannula as needed for shortness of breath. Observations revealed this resident was receiving oxygen at 3 LPM. Interviews with LPNs revealed that licensed nurses were responsible for setting and monitoring the oxygen flow rate, but one LPN admitted to not always checking the setting when providing care. The Director of Nursing stated that her expectation was for staff to monitor and follow physician orders for oxygen administration.