Failure to Follow Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the care plan interventions as written for a resident with a history of asthma who required oxygen therapy. The resident's care plan specified the use of oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, and the physician's order matched this intervention. However, during an observation, the resident was found receiving oxygen at a flow rate of 3 liters per minute, which was not in accordance with the care plan or physician's order. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen should have been set at 2 liters per minute and that staff are expected to follow the care plan and physician's orders as written. The discrepancy between the oxygen flow rate provided and the documented care plan and physician's order was acknowledged as a failure to follow the individualized plan of care. The resident involved had a moderately impaired cognitive status and diagnoses including cough and wheezing, and was receiving oxygen therapy at the time of the deficiency.