Oxygen Administration Not in Accordance with Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to a physician's order for one resident with chronic obstructive pulmonary disease and chronic systolic heart failure. The resident was observed receiving oxygen via nasal cannula at a rate of 2.5 to 3 liters per minute, despite a physician's order specifying continuous oxygen at 2 liters per minute. Staff reported that the resident often removed the nasal cannula at night, and in response, staff increased the oxygen flow rate without obtaining a new physician's order or titration instructions. Review of the clinical record confirmed there was no order to increase or titrate the oxygen flow rate based on oxygen saturation readings. The facility's policy required medications, including oxygen, to be administered strictly according to prescriber orders, and any changes or clarifications were to be documented. The Director of Nursing confirmed that staff increased the oxygen flow rate without proper authorization or documentation, and the clinical record lacked any order supporting this change.