Oxygen Administration Exceeded Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to the physician's order for a resident with a history of cough and wheezing. The physician's order specified oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath or oxygen saturation of 93% or below. However, during multiple observations, the resident was receiving oxygen at a flow rate above 3 liters per minute, with one instance recorded at 3.4 liters per minute. The LPN on duty confirmed that the oxygen was typically set at 3 liters per minute and acknowledged that the setting had not been changed that morning, despite the physician's order specifying a lower rate. Further interviews revealed that the LPN was aware that the oxygen should not be adjusted without a new physician order and that exceeding the prescribed rate could have adverse effects. The Director of Nursing also confirmed that nurses are expected to check and follow the physician's order every shift. The resident involved had moderately impaired cognition, as indicated by a BIMS score of 9, and was receiving oxygen therapy at the time of the deficiency.