Failure to Ensure Correct Oxygen Flow Rate for Resident
Penalty
Summary
A deficiency was identified when a resident requiring oxygen therapy for conditions including COPD, heart failure, and dementia was observed with their oxygen flow rate set incorrectly on multiple occasions. On two separate days, the oxygen flow meter was set slightly above 1.5 liters per minute, rather than the physician-ordered 2 liters per minute via nasal cannula. During one observation, the nasal cannula tubing was not properly positioned under the resident's nose. An LPN, when questioned, initially stated the oxygen was set at 2 liters but upon verification, acknowledged the flow rate was incorrect and adjusted it to the prescribed level. The resident's care plan specified oxygen therapy as needed for shortness of breath, with instructions to administer oxygen as ordered by the physician. The resident's medical record confirmed the order for 2 liters of oxygen via nasal cannula as needed. The DON confirmed that nursing staff had been previously in-serviced on the correct method for checking oxygen flow rates, which involves viewing the flow meter at eye level to ensure accuracy. Despite these instructions, the oxygen was not set at the correct rate as ordered.