Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and hemiplegia had a physician's order to receive two liters of oxygen via nasal cannula every shift. During a medication administration, the resident was observed with the nasal cannula out of her nose and lying on her chest, not receiving oxygen as ordered. The Qualified Medication Aide (QMA) educated the resident and assisted with replacing the nasal cannula in her nose. However, the oxygen concentrator was set to five liters instead of the ordered two liters. The QMA recognized the discrepancy but was unable to adjust the oxygen level and indicated she would notify the nurse, yet there was no observation of her reporting the issue before leaving to continue other tasks. Later, the resident was again observed with the nasal cannula in place, but the oxygen concentrator remained set at five liters. After reviewing the order, the nurse consultant confirmed the resident should be on two liters and adjusted the setting accordingly. The facility's oxygen therapy procedure required verification of the resident and physician order, which was not followed at the time of the initial observation.