Oxygen Therapy Not Administered as Ordered
Penalty
Summary
Staff failed to administer oxygen therapy to a resident as ordered by the physician. The physician's order specified oxygen via nasal cannula at 2 liters per minute (LPM) as needed for shortness of breath, wheezing, or oxygen saturation below 92%. However, multiple observations over two days showed the resident's oxygen concentrator was set at 4 LPM, not the ordered 2 LPM. The resident was receiving oxygen at this higher rate via nasal cannula during each observation. Interviews with staff revealed that charge nurses were responsible for ensuring residents received oxygen as ordered, but the oxygen flow rate for this resident had not been checked that day. The LPN confirmed the discrepancy between the order and the actual setting. The Director of Nursing also confirmed the resident's order was for 2 LPM and acknowledged that the resident's care plan did not address the use of oxygen therapy, despite the resident receiving it.